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CLINICAL PATHWAY
SIROSIS HEPATIS ec ALKOHOLIK
DISUSUN OLEH:
SRI INDAH YANI (02091001165)
MANOGU
RUDOLF A
(03091001182)
RUSKAMTO (04091001151)
dr. NAMSO SARAGIH, Sp.PD Sign up to vote on this title
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RSUD dr. DJASAMEN SARAGIH PEMATANGSIANTAR
FAKULTAS KEDOKTERAN UNIVERSITAS ISLAM SUMATERA UTARA 2011
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STATUS ORANG SAKIT Tanggal Masuk : 30 April 2011
I.
II. II.
ANAMNESE PRIBADI
Nama
: Lukmanul Hakim Damanik
Umur
: 64 64 tahun
Jenis Kelami amin
: Laki-laki
Status
: Menikah
Pekerjaan
: Supir Truk
Suku
: Batak
Agama
: Kristen Protestan
Alamat
: Jl. Pane No.551 Pe P ematangsiantar
ANAMN AMNESE PENYAKIT
Kelu Keluha han n Uta Utama ma : Perut Perut memb membes esar ar Telaah
: - Hal in ini te telah di d ialami OS O S se s ejak 3 bulan ya yang la l alu d tambah tambah memb membes esar ar dalam dalam 1 mingg minggu u tera terakh khir ir ini. ini. membesar disertai dengan mata OS menguning. - OS juga mengeluhka mengeluhkan n mual (+) dan muntah muntah (+) dialami dialami Sign up to vote on this title
kurang lebih 5 hari yang lalu, frekwensi Useful Not usefulmuntah kura lebih 3-4 kali per hari isi muntahan apa yang baru sa
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- Riwayat Riwayat transfus transfusii darah darah (-) (-) - BAK seper seperti ti teh teh dijumpa dijumpaii - BAB (+) (+) norm normal al RPT
: - Penyakit kuning kurang lebih 2 tahun yang lalu.
RPO
: - Tidak jelas
III. III. ST STAT ATUS US PRES PRESEN ENT T Keadaan Umum
Sensorium
: Compos mentis
Tekanan darah
: 160/90 mmHg
Pols
: 86 x/i
RR
: 26 x/i
Temperatur
: 37,4oC
Keadaan penyakit
Pancaran wajah
: lemah
Anemia
: (-)
Ikterik
: ( +)
Cyanosis
: ((-)
Oedem
: ( +) Sign up to vote on this title
Dyspnoe
: (-)
Reflex fisiologis
: normal
R fl
t l
i
l
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Keadaan Gizi
TB : 168 cm
BB BB
RBW =
:
70 Kg
X 100%
TB – 100 70
=
x 100%
168 – 100 = 102 %
KU/KP/KG
: Sedang / sedang/ kurang
Lingkar perut
: 130 cm
IV. IV. PEME PEMERI RIK KSAA SAAN FISI FISIK K
Kepala
:
- Mata
: Refleks cahaya +/+ Pupil isokor isokor kiri = kanan Sklera ikterik ( + )
- Hidung
: Simetris, septum normal ; sekret (-)
- Mulut
: Bau na nafas ya yang kh khas (f (fetor he hepatikum), mu mucosa bi bibir b
beslag (-) ; lidah tremor (-); tonsil hiperemis (-), Fari Hiperemis (-)
L h
L t kT
h
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Useful
di l S id
i
(+)
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Batas paru hati :
relativ : ICR V Absolut : ICR VI
Batas Jantung Jantung : - Kiri : ICR ICR V, ICM Medi LMCS
Kanan : Linea parasterna kanan Atas : ICR II – III kiri - Auskulta Auskultasi si = suara suara pernafas pernafasan an : Vesikul Vesikuler er suar uar tam tamba baha han n
Abdomen Abdomen
= - Inspeksi Inspeksi
: Tida Tidak k diju dijum mpai pai
: acites acites mengkilat mengkilat Collaretal vein (+) Caput medusa (-) Smilling umbiliens (+)
- Palp Palpas asii
: soep soepel el nyeri tekan (-) undulasi (+) hati : tidak teraba lien : teraba (Schuffner II, Hacket II) Ginjal : tidak teraba
- Pe Perkusi
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: Sh Shifting du dullnes (+ (+)
Useful
- Auskultas Auskultasii : Double Double sound (+) Pi
DBN
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V. PEMERIKSAAN LABORATORIUM
Darah rutin
:
Hb
LED
: 12,2 gr% : 12 mm/jam : 9700/mm3
Leukosit
Hitung Jenis
Trombosit
: 115000 /ul
Hematokrit
: 42 %
: Eosinofil
: 2%
Basofil
: 0%
N Batang
: 2%
N.Segment
: 60%
Limfosit
: 25%
Monosit
: 3%
Urine Rutin
- Wa Warna
: kuning peka
- Protein
: (-)
- Reduksi
: (-)
- Biliburin
: (+)
- Sedimen Sedimen leukos leukosit it : 1-2 /LPB /LPB - Sedimen Sedimen epitel epitel LFT
=
: 1-2/LP 1-2/LPB B
SGOT SGPT HbsAg Anti HBs
: 70 u/L : 68 u/L
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Ginjal
: Kanan, kiri normal
Uterus
: normal
Abdo Abdom men : Asci Ascittes (+)
VI. DIAG DIAGNO NOSA SA BA BANDIN NDING G
-
SIROSIS HEPATIS HEPATIS ec ALKOHOLIK ALKOHOLIK
-
HEPATITIS HEPATITIS KRONIK KRONIK
-
HEPATOMA HEPATOMA
-
CHF
VII. VII. DIAGNO DIAGNOSA SA SEMENT SEMENTARA ARA
-
SIROSIS HEPATITIS HEPATITIS ec ALKOHOLIK ALKOHOLIK
VIII. PENATALAKSANAAN
Aktivitas Diet Diet
: Bed rest total : 1.Di 1.Diet et renda endah h gar garam (30 mg/ha g/harri) 2.Diet Hati III
Medi Medika kam men :
IVFD IVFD Dext Dextro rose se 20 gtt/ gtt/ii
Inj. Inj. Cefo Cefota taxi xime me 1 gr Useful gr/12 2 jam jam Not useful 1 gr/1
Inj.Furosemide 10 mg 1 amp/ 12 jam
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Bertujuan untuk mengatasi mual muntah
Menambah nafsu makan
Menurunkan berat badan
Bertujuan untuk mencegah infeksi sekunder
IX. RENCANA PENJAJAKAN
-
Pem Pemeri eriksaa ksaan n Vira Virall Mar Marke kerr (Hb (HbsA sAg g dan dan Ant Anti HBs HBs), ), HBV DNA, DNA,
RNA -
Monitoring lingkar perut
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PENANGANAN HARI KE HARI
Indikasi Opname
Perut membesar
Luaran LOS yang diharapkan Nama : Lukmanul Hakim Damanik
Lingkar perut : 130 cm Menghilangkan mual muntah 6 hari Tanggal masuk : 30 April 2011 Tanggal perawatan : 30 April 2011
Dimulai Pada Perawatan Di Poliklinik Aktivitas Bed rest Diet MI Diet Hati III Kalori 2000 kkal Protein 50 gr Lemak 40 gr Karbohidrat 349 kkal Diet rendah garam (30mg/hari) Penjajakan
Keterangan
Darah rutin : Hb Led Leukosit Trombosit Hem Hematok atokrrit
: 12,2 gr% : 12 mm/jam : 9700/mm 3 : 115000/uL : 42% 42%
Hitung Jenis Eosinofil Basofil N Batang N.Segment Limfosit Monosit
: 2% : 0% : 2%Sign up to vote on this title : 60% Useful Not useful : 25% : 3%
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Terapi Penunjang
Terapi Medikamen
Pengukuran Evaluasi keluhan
Konsul Target sementara
Dischange plannin ning
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IFVD D5% 20 gtt/i Inj. Ranitidine 1 amp /12 jam Curcuma 3 x 1
Mengatasi mualmuntah Penam nambah bah n makan. Untuk mengatasi Inj. Cefotaxime 1 gr/12 jam infeksi Inj.Furosemide 10 mg1 amp/ 12 Untuk mengatasi ascites dan oedem jam sda 12.5 mg mg 2 x 1 Captoril 12 Untuk Spironolacton 100mg2 x 1 menormalkan tekanan darah TD, HR,RR, Temperature, BB, lingkar perut, balance cairan Perut membesar, tekanan darah tinggi, mual-muntah dan menambah nafsu makan Internist Mengurangi acites Menormalkan tekanan darah Mengatasi mual muntah Menambah nafsu makan
Renca ncana dan tujuan pengoba obatan dan menerangkan pada pasien tentang penyakitnya.
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DETAIL PENANGANAN DARI HARI KE HARI Ak tivita s Diet
P en en ja jaj ak ak an an
H ari ke I Bed rest to ta l MI Diet Hati III Kalori 2000 kkal Protein 50 gr Lemak 40 gr Karbohidrat 349 kkal Diet rendah (30mg/hari)
Hari k e II Bed rest to ta l MI Diet Hati III Kalori 2000 kkal Protein 50 gr Lemak 40 gr Karbohidrat 349 kkal Diet rendah garam (30mg/hari)
H ari ke III Bed Re st to ta l MI Diet Hati III Kalori 2000 kkal Protein 50 gr Lemak 40 gr Karbohidrat 349 kk Diet rendah (30mg/hari)
-M on on it ito ri rin g b er era t b ad ad an an
M on on it ito ri rin g b er era t
IFVD D5% 20 gtt/i Inj. Ranitidine 1 amp /12 jam Curcuma 3 x 1
IFVD D5% 20 gtt/i Inj. Ranitidine 1 amp/12 jam Curcuma 3 x 1
IFVD D5% 20 gtt/i Inj. Ranitidine 1 am Curcuma 3 x 1
Inj. Cefotaxime 1 gr/12 jam Inj.Furosemide 10 mg 1 amp/ 12 jam Captoril 12.5 mg 2 x 1 Spironolacton 100mg 2 x 1
Inj. Cefotaxime 1 gr/12 jam Inj.F nj.Fur uros osem emid idee 10 mg 1 amp/ 12 jam Captoril 12.5 mg 2 x 1 Spironolacton 100mg 2 x 1
Inj. Cefotaxime 1 g Inj.F nj.Fur uros osem emid idee amp/ 12 jam Captoril 12.5 mg 2 Spironolacton 100m
TD
: 16 0 /90 mm m mH g
TD
: 15 0/90 mm mmHg
TD
: 150 /80 m
HR
: 86x/i
HR
: 82 x/i x/i
HR
: 72 x/i x/i
RR
: 26 x/i
RR
: 24 x/i x/i
RR
: 24 x/i x/i
T
: 37,4 o C
T
: 37 ,0o C
T
: 3 6,8o C
BB
: 70 k g
BB
: 69 k g
BB
: 6 7,5 k g
garam
P em em er erik sa sa an anLFT Serol Serologi ogi marker marker (HbsA (HbsAg g dan Anti HBs)
Terapy Supportive Terapi Medikamen
P en gu k uran
Lingkar perut: 130 cm
Lingkar perut: 128 cm
Balancing cairan:
Balancing cairan: Useful
Input Input : - minum: minum: 1500 cc
Input Input : - minum: minum: 1100 cc
Lingkar perut: 126
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ma
Balancing cairan: Not useful Input : - minum: minum: m
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Co n tro l
K o n su l Target
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Mual (+) Muntah(+)
Mual/muntah (+) b
Tekanan darah tinggi
Tekanan darah mulai turun
Tekanan darah mul
Nafsu makan mak an me nuru n -
Nafsu makan mak an masih m asih menurun men urun Nafsu Nafs u mak an mulai m ulai Me M -
ngurangi acites -
engurangi acites Me
-
-
engatasi mual/muntah
Me
-
-
M
Me
-
-
engatasi mual/
- Meningkatkan nafsu nafsu makan
ningkatkan nafsu makan -
engurangi acite
- Menormalkan tekanan darah - Menormalkan tek
normalkan tekanan darah
ngatasi mual/muntah
Planning
WOC - Diabetes Melitus
Mu al (+) Mu n tah (+)
Sementara
Discharge
pathways gondok
M
-
engecilkan ling
engecilkan lingkar perut
Me
ngecilkan lingkar perut Hind Hindar arii meng mengko kons nsums umsii minuman beralkohol Isti
urangi aktivitas berat
K
makanan yang
rahat total
Ak tivita s Diet
P en jajakan
H ari ke IV Bed rest to ta l MI Diet Hati III Kalori 2000 kkal Protein 50 gr Lemak 40 gr Karbohidrat 349 kkal Diet rendah garam (30mg/hari)
H a ri k e V H ari k e V I B ed rest M ob ilisas i MI MI Diet Hati III Diet Hati III Kalori 2000 kkal Kalori 2500 kka Protein 50 gr Protein 90 gr Lemak 40 gr Lemak 60 gr Karbohidrat 349 kkal Karbohidrat 404 Sign up to vote on this title Diet rendah garam Diet rendah garam (30mg/hari) (30mg/hari) Useful Not useful
Mo n itoring be berat ba badan
Mon ito rin g be berat ba bad an
M on itorin g be bera
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BB
pathways gondok
WOC - Diabetes Melitus
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: 66 k g
BB
: 65 k g
BB
: 63 kg
Lingkar perut: 124 cm
Lingkar perut: 122 cm
Lingkar perut: 122
Balancing cairan:
Balancing cairan:
Balancing cairan:
Input Input : - minum: minum: 1200 cc
Input : - minum: 1300 cc
Input : - minum:
-
-
ma
in f
-
in
fus
Output Output : - urin urin : 3400 cc
Output Output : - urin urin : 3250 3250 cc
-
fe s
Output Output : - urin urin : 360 36 fe
-
ses: 70 cc
es: 70 cc -
akan: 5
fus : 1500 cc
us : 1500 cc
-
-
akan: 55 cc
kan: 55 cc -
m
ses: 60
-
IW
-
I
Simptom
L: 450 cc Ukuran perut mulai mengecil
WL: 450 cc WL: 45 Ukuran perut mulai mengecil Ukuran perut mulai
Control
Mual/muntah (+) berkurang
Mual/muntah (+) berkurang
Tekanan darah mulai turun
Tekanan darah normal
K o n su l Target Sementara
Nafsu makan mak an mu lai ad a -
Me
ngurangi acites -
-
M
engurangi acites Me
normalkan tekanan darah -
Mual/muntah (-)
-
-
engurangi acite M
engecilkan lingkar perut
-
engecilkan ling
Me
ngatasi mual/muntah -
Me
ningkatkan nafsu makan -
Me
ngecilkan lingkar perut
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Rencana Jangka Panjang •
Mempertahankan fungsi hati
•
Pengontrolan tekanan darah
•
Mengontrol pola hidup sehat
•
Penjajakan :
•
-
Pemeriksaan darah rutin
-
Pemeriksaan urin rutin
-
LFT
-
Serologi viral marker
-
USG
Alarm symptom :
-
Perut semakin membesar
-
BAK berwarna teh pekat - Tens Tensii ting tinggi gi - Muntah-m Muntah-munt untah ah terus terus - Tidak Tidak mau mau makan makan •
Discharge planning :
-
Kontr Kontrol ol ke ke poli poli gas gastr trol olog ogii seca secara ra ter terat atur ur
-
Makan kan obat teratu atur Sign up to vote on this title
-
Istirahat ya yang cukup
-
Hind Hindar arii minu minuma man n bera beralk lkoh ohol ol
Useful
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Hind Hindar arii akt aktiivita vitass ber berat at
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