MAPPING KASUS +SOAP

MAPPING KASUS

STRESS, INFECTION

Relative insulin defisiency in DMT2

Cortisol  Chatecholamine 

Gluconeogenesis 

Absent or minimal KETOGENENESIS

Proteolysis  Protein synthesis 

HYPERGLYCEMIA

GLUCOSURIA (osmotic diuresis)

Loss of water & electrolytes (Volume depletion)

Dehydration

Vasoconstriction

SHOCK HYPOVOLUMIC

METABOLIC ACIDOSIS

Cold and clammy acral

Electrolyte Disorder

HYPEROSMOLAR

Inadequate perfusion

Cell hypoxia

Fall in pH

Energy deficit Anaerobic metabolism

Lactic acid accumulation

V. SOAP Subjective

Objective

Assessment

Planning

Penurunan kesadaran

VS:

DDx

Ptx

GCS 223

Hipoglikemia

IVFD NS 10-20cc/ kgBB

TD 71/36 mmHg

Shock Hipovolemik

dalam 1 jam pertama

nadi 115x/menit

Shock Cardiogenik

RR 28x/menit

Shock Sepsis

PDx

 Akral dingin

ECG

temp axilla 360C

DL, BJ Plasma WDx

turgor menurun (+/-)

Shock Hipovolemik e.c

PMo

diuresis e.c susp HHS

VS post koreksi

dd KAD

Evaluasi jika respon +  dilanjutkan;  jika respon (-) maka shock cardiogenic  beri vasoactive agent

Penurunan kesadaran

VS:

DDx

Ptx

Poliura,

GCS 223

HHS

penatalaksanaan)

TD 71/36 mmHg

DKA

Rehidrasi

Nocturia,

Polidipsia, Poliphagia

nadi 115x/menit

(lihat

Insulin

RR 28x/menit PDx

 Akral dingin

GDA,

BGA,

UL,

Kulit kering

Osmolality serum, Keton

Turgor kesan normal

serum, SE

Mukosa kering PMo

Lidah kering, hiperemi

GDA, serum elektrolit Glukosuria (+)

(awasi

kondisi

Ketonuria (-)

hypernatremia

setelah

Keton serum 2.1 mg/dL

rehidrasi NS dan kondisi hipokalemi)

GDA 1848 mg/dL HbA1c 12.4 %

Osmollity

404.89

mOsm/L

Sesak,

Batuk

produktif, Demam

VS: RR 28x/menit temp axilla 390C

DDx -

PTx

Bacterial

 Antibiotik

Pneumonia

 Antiinflamasi

-

Viral Pneumonia

Topikal bronkodilator

PCH (+) Retraksi dinding dada (+) Rh kasar +/Wh +/-

PDx DL,

BGA,

Kultur

dahak, kultur darah Radiologi:

Thorax Rontgen

Rö Thorax: Perselubungan hemi thorax kanan

PMo RR BGA