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Studi Kasus SMF Ilmu
Penyakit Jantung
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PROFIL PASIEN
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Alasan MRS : Pasien rujukan dari RS Haji, dengan keluhan panas
sumer2, sesak, batuk berdahak selama 1 minggu.
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Vital Sign/Laboratory Data
Initial/Follow up
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Vital Sign/Laboratory DataInitial/Follow up (lanjutan)
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Chronic parenchimal kidney diseasedisertai bilateral.
Kista ginjal kanan pole tengah Susp: batu ginjal kanan pole tengah
Pembesaran prostat
Hepar/lien/GB/pancreas/bladdertak tanpak kelainan.
Hasil USG Abdomen: 23/05/2012
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Hasil konsultasi terhadap data hasilUSG Abdomen dan data laboratorium
Kesimpulan: saat ini dibidang IPD
pasien mengalami DM II + CKD IV(GFR=21,3)
Tgl 18/05/2012
IPD
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Current Drug Therapy
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Time Line
(Circle actual administration times and recordappropriate medications and meals below.)
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J i Ob t T l
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No
Jenis ObatRegimen
Dosis
Tanggal
Nama dagang
/generik16/5 17/5 18/5 19/5 20/5 21/5 22/5 23/5 24/5
1 O2 500 cc/24 jam
2 IVFD PZ 500cc/24 jam
3 Furosemid 1 amp0 - 0
4 Ambroksol 3 x 1tab
5 Cefixime 2 x 100 mg //
6 Paracetamol 3 x 1 tab
7 Irbesartan 150 mg00
8 ISDN 3 x 5 mg
9 Bisolvon
nebule
Tiap 8 jam
10 Levemir 004 U
11 Allopurinol 3 X 100 mg 1x
10015
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16
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Treatment for
Heart Failure
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ecommen a ons o armaco og ca rea men s
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ecommen a ons o armaco og ca rea men sindicated in Potentially all Patients with Symptomatic
(NYHA class II-IV) Systolic Heart Failure
ESC Guidelines for the
diagnosis and
treatment
of acute and chronic
heart failure 2012.
European Heart Journal
(2012)33, 1787184718
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LGORITM THER PY
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patients with symptomatic HF (NYHA class IIIV)and LV
systolic dysfunction
ESC Guidelines for the diagnosis and treatmentof acute and chronic heart failure 2012. European Heart Journal (2012)33, 17871847
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Terapi HF: ARBTgl Obat Dosis Indikasi ESO Monitoring
16/5-
24/5
Irbesartan 150 mg-0-0 Menghambat sistem RAAS
sehingga menurunkan tekanan
darah. Pemberian ini
menggantikan ACE Inhibitor
yang memiliki ESO pada paru
Hiperkalemia TD, HR,
elektrolit
Data Klinik Nilai
Normal
Tanggal
16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12
Tekanan darah 120/80 170/100 200/130 140/80 140/80 140/90
Nadi 60-100 x /
mnt
100 88 84 80 88 100 120 120 84
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Angiotensin Reseptor Blocker for HF
(Cochrane Review 2012)
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Pharmacokinetic Profile of ARB
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E id B d ARB
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Evidence Based ARB
Terapi HF Di retik
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Terapi HF: DiuretikTgl Obat Dosis Indikasi Eso Monitoring
16/5-
24/5
Furosemide 40 mg-0-0 Mengurangi load
cairan akibat gagal
jantung
Hiperuricemia (40%),
Hipokalemia (14-
60%)
TD, K, edema
paru, sesak
Data Klinik Nilai
Normal
Tanggal
16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12
Sesak - + -(berkurang)
- - -
Input250 cc 250 cc 250 cc 250 cc 250 cc 250 cc 250 cc 250 cc 250 cc
Output 750 cc/
3 jam
1400 cc/
24 jam
900 cc/
24 jam
600 cc/
24 jam
300 cc/
24 jam
500 cc/
24 jam
400cc/
24 jam
Defisit
/excess
Input=
ouput
25
Defisit belum dapat ditentukan karena input diketahui hanya dari volume
infus yang masuk ke tubuh pasien
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ISDN
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ISDNTgl Obat Dosis Indikasi ESO Monitoring
17/5;
24/5
ISDN 3x5 mg Sebagai vasodilator
mekanpreload &afterload, me kan stroke
volumemenurunkan
tekanan darah pada kondisi
AHF
Hipotensi, sakit
kepala
TD
Pada tgl 17/5, pasien mengalami peningkatan tekanan darah yang
signifikanISDN digunakan sebagai vasodilator untuk mengatasi kondisi
hipertensi pada pasien dengan AHF.
Pengunaan nitrat sebaiknya dihindari pada pasien dengan TD sistolik
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Regimen Doses of Intravenous Vasodilators
ESC Guidelines for the diagnosis and treatmentof acute and chronic heart failure 2012. European Heart Journal (2012)33, 17871847
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Treatment for
PPOK
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AMBROXOL
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AMBROXOLTgl Obat Dosis Indikasi ESO Monitoring
17/5;
24/5
Ambroxol 3x 30mg Mukolitik pada batuk
produktif
Gangguan GI
ringan
Produksi
dahak danfrekuensi
batuk
32
Data Klinik Nilai
Normal
Tanggal
16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12
Batuk - + - - - -
Dahak - + - - - -
Sesak - + berkurang - - -
BROMHEXIN HCl
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BROMHEXIN HClTgl Obat Dosis Indikasi ESO Monitoring
17/5;
24/5
Bromhexin
HCl
Tiap 8 jam
nebul
Mukolitik pada batuk
produktif
Batuk atau
bronkospasme
Batuk, Sesak,
Dahak
33
Data Klinik Nilai
Normal
Tanggal
16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12
Batuk - + - - - -
Dahak - + - - - -
Sesak - + berkuran
g
- - -
CEFIXIME
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CEFIXIMETgl Obat Dosis Indikasi ESO Monitoring
17/5;
24/5
Cefixime 3x1 tab Antibiotika pada PPOK Diare WBC, HR,
Suhu
34
Data Klinik Nilai
Normal
Tanggal
16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12
WBC 3,7010.1
x103/UL
11,9
x10311,9 x103
- - - -
HR 80-100 100 88 84 80 88 100 120 120 84
Suhu 36,5 - 37 37,8 37 36,4 36,5 36,7 36,3 36,5 36,6 36
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(NICE, 2010)
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Treatment forDiabetes
Mellitus
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DETEMIR
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DETEMIRTgl Dagang/
Generik
Regimen
Dosis
Indikasi ESO Monitoring
20/5-24/5
Levemir 0-0-4 U Mengontrol glukosa darah Hipoglikemia GDA, GDP,GD2JPP
37
Data
Klinik
Nilai
Normal
Tanggal
15/5/
12
17/5/1
2
18/5/
12
19/5/1
2
20/5/1
2
21/5/
12
22/5/12 23/5/1
2
24/5/1
2
GDA 268
GDP 125
GD2JPP 125
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Jenis Insulin Berdasarkan Farmakokinetiknya
(DiPiro et al, 2008. Pharmacotherapy: A Pathophysiologic Approach, 7thEdition)38
PARACETAMOL
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PARACETAMOLTgl Obat Dosis Indikasi ESO Monitoring
17/5;
24/5
Parasetamol 3x1 tab Demam Ruam kulit,
hepatotoksik(peningkatan
OT/PT)
Suhu
39
Data Klinik Nilai
Normal 16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12
Suhu 36,5 - 37 37,8 37 36,4 36,5 36,7 36,3 36,5 36,6 36
ALLOPURINOL
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ALLOPURINOLTgl Obat Dosis Indikasi ESO Monitoring
17/5;
24/5
Allupurinol 3x1 tab Menurunkan kadar asam
urat
Hipersensitifitas Asam urat
darah
40
Data Lab Nilai
Normal
Tanggal
16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12
Asam Urat 2,67,2 13,1
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Pharmacotherapeutic
Goal
Monitoring
Parameter
Desired
Endpoint
Monitoring
Frequency
Mengatasi sesakTerjadinya
sesak
Berkurangnya
sesakTiap hari
Ronchi
Tidak ada
ronchi
Mengatasi demam Suhu 36 - 37 C Tiap hari
Mengontrol tekanan
darahTD
< 140/ 90
mmHg (JNC
VIII)
Tiap hari
Mengontrol gula darah GDP< 110 mg/ dL
(AACE)3 hari sekali
GD2PP< 140 mg/ dL
(AACE)
HbA1c< 6,5 mg/ dL
(AACE)Tiap 3 bulan
Goals of the Therapy
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Goals of the Therapy
Pharmacotherapeutic
GoaltimMonitoring
Parameter
Desired
Endpoint
Monitoring
Frequency
Mengatasi sesak Terjadinya sesakBerkurangnya
sesakTiap hari
Ronchi Tidak adaronchi
Mengatasi demam Suhu 36 - 37 C Tiap hari
Mengontrol tekanan
darahTD
140/ 90
mmHg (JNC
VIII)
Tiap hari
Mengontrol gula darah GDP110 mg/ dL
(AACE)3 hari sekali
GD2PP140 mg/ dL
(AACE)
HbA1c6,5 mg/ dL
(AACE)
Tiap 3 bulan
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Goals of the Therapy
PharmacotherapeuticGoal
MonitoringParameter
DesiredEndpoint
MonitoringFrequency
Mengatasi nyeri dada Nyeri dadaBerkurangny
a nyeri dadaTiap hari
Mengatasi batukBatuk
berdahak
Tidak terjadi
batukTiap hari
Dahak dapat
keluarTiap hari
Mengontrol asam uratKadar asam
urat
2,6-7,2 mg/
dL3 kali sehari
Mengatasi infeksi Suhu 36 - 37 C Tiap hari
WBC4,5.103-
10.103/ mm3Berkala
RR 20X/ menit Tiap hari
Nadi 80-100 bpm Tiap hari
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Goals of the Therapy
PharmacotherapeuticGoal
MonitoringParameter
DesiredEndpoint
MonitoringFrequency
Mengatasi nyeri dada Nyeri dadaBerkurangnya
nyeri dadaTiap hari
Mengatasi batuk Batuk berdahakTidak terjadi
batukTiap hari
Dahak dapat
keluarTiap hari
Mengontrol asam urat Kadar asam urat 2,6-7,2 mg/ dL 3 kali sehari
Mengatasi infeksi Suhu 36 - 37 C Tiap hari
WBC4,5.103-10.103/
mm3Berkala
RR 20X/ menit Tiap hari
Nadi 80-100 bpm Tiap hari
DRUG THERAPY ASSESSMENT
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DRUG THERAPY ASSESSMENTWORKSHEET (DTAW)
Type ofproblem Assessment Presence of Drug-Related Problem Comments/Notes
Correlation
between Drug
Therapy and
Medical
Problem
Are there drug without a
medical indication ?
Are any medication
unidentified (are anyunlabeled or are any-prior
to admission clinic visit-
unknown) ?
Are there untreated
medical conditions ?
Do they require drug
therapy ?
1. A problem exists.
2. More information
is needed for
a determination.
3. No problem
exists or an
intervention is not
needed.
1. Tidak dilakukan
kultur sputum
hingga 7 hari
pasien MRS
2. Tidak febris 17/5-24/5 namun
diberikan PCT. PCT
diberikan ketika
demam saja.
C DTAW (1)
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Cont. DTAW (1)
Type ofproblem Assessment Presence of Drug-Related Problem Comments/Notes
Appropriate
Drug Selection
What is the comparative
efficacy of the chosen
medication(s) ?
What is the relative safety
of the chosen
medication(s) ?
Has the therapy beentoilered to this individual
patient ?
1. A problem exists.
2. More information
is needed for
a determination.
3. No problem
exists or an
intervention is not
needed.
Pasien mendapatkan
Levemir pada tgl 20,
namun tidak ada data
mengenai monitoring
GDP.
T f P f D
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Type of
problem Assessment
Presence of Drug-
Related Problem Comments/Notes
Drug regimen Are the prescribed dose anddosing frequency appropriate-
within the usual therapeutic
range and/or modified for
patient factors ?
Is the route/dosage
form/mode of
administration appropriate,
considering efficacy, safety,convenience, patient
limitation, and cost ?
Are doses scheduled to
maximize
therapeutic effect and
compliance and to minimizeadverse effect, drug
interactions, and regimen
complexity ?
Is the length or course of
therapy appropriate ?
1. A problem exists.
2. More informationis needed for
a determination.
3. No problem
exists or anintervention is not
needed.
Pasien mendapatkan
terapi alupurinol dosis
3 x 100 mg.berdasarkan literatur
(Ganiswara, ed 4,
P.221) alopurinol
mengalami
biotransformasi oleh
enzim xantin oksidasemenjadi aloxantin
yang waktu paruhnya
lebih panjang
daripada alupurinol,
sehingga cukup
diberikan 1 x 100 mg.
C t DTAW (2)
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Cont. DTAW (2)
Type of
problem Assessment
Presence of Drug-
Related Problem Comments/Notes
1. Correlation
between Drug
Therapy and
Medical
Problem
Are there drug without a
medical indication ?
Are any medication
unidentified (are anyunlabeled or are any-prior
to admission clinic visit-
unknown) ?
Are there untreated
medical conditions ?
Do they require drug
therapy ?
1. A problem exists.
2. More information
is needed for
a determination.
3. No problem
exists or an
intervention is not
needed.
1. Tidak dilakukan
kultur sputum
hingga 7 hari
pasien MRS
2. Tidak febris 17/5-24/5 namun
diberikan PCT. PCT
diberikan ketika
demam saja.
Cont. DTAW (4)
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Cont. DTAW (4)Type of
problem Assessment
Presence of Drug-
Related Problem Comments/Notes
Therapeutic
duplication
Are there any therapeutic
duplications?1. A problem exists.
2. More information
is needed for
a determination.
3. No problem
exists or an
intervention is not
needed.
.
Drug allergy
Intolerance
Is the patient allergic to or
intolerant of any medicines
(or chemically related
medications)
currently being taken ?
Is the patient using any
method to alert health care
providers of the
allergy/intolerance (or
serious medical problem) ?
Adverse Drug
Events
Are there symptoms or
medical problems that may
be drug induced ?
What is the likelihood that
the problem is drug
related?
Cont. DTAW (5)
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Cont. DTAW (5)Type of
problem Assessment
Presence of Drug-
Related Problem Comments/Notes
Interactions :
Drug-drug,
Drug-Disease
Drug-nutrient,
and
Drug-Laboratory
Test
Are there drug-drug
interactions ?
Are they clinically
significant ?
Are any medications
contraindicated(relatively
or absolutely) given patient
characteristic and
current/pass disease
states ?
Are there drug-nutrient
interactions ?
Are they clinicallysignificant ?
Are there drug-laboratory
test interactions ?
Are they clinically
significant ?
1. A problem exists.
2. More information
is needed for
a determination.
3. No problem
exists or an
intervention is not
needed.
.
Cont. DTAW (6)
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Co t. (6)
Type of
problem Assessment
Presence of Drug-
Related Problem Comments/Notes
Social orRecreational
Drug Use
Is the patients current useof social drugs problematic ?
Could the sudden decrease
or discontinuation of social
drugs be related to patient
symptoms (e.g., withdrawal)?
1. A problem exists.
2. More
information is
needed for
a determination.
3. No problem
exists or an
intervention is not
needed.
.
Failure to
Receive Therapy
Has the patient failed to
receive medication due to
system error or
noncompliance?
Are there factors hindering
the achievement of
therapheutic efficacy?
Cont. DTAW (7)
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( )
Type of
problem Assessment
Presence of Drug-
Related Problem Comments/Notes
Financial Impact Is the chosen medication(s)cost effective?
Does the cost of drug
therapy represent a financial
hardship for the patient ?
1. A problem exists.
2. More
information is
needed for
a determination.
3. No problem
exists or an
intervention is not
needed.
.
PatientKnowledge of
Drug Therapy
Does the patient understandthe purpose of his or her
medication(s), how to take it
and the potential side effect
of therapy ?
would the patient benefit
from education
tool (e.g., writen patient
education sheets, wallet
cards and reminder
packaging) ?
DRUG THERAPY PROBLEM LIST (DTPL)
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DRUG THERAPY PROBLEM LIST (DTPL)
Date Problem Action
16/5/1218/5/12
Pasien tidak mengeluh demam. Nilaisuhu tubuh normal, tidak terlihat
meningkat.
Penggunaan parasetamol bila perlusaja
16/5/12 Pasien tidak perlu mendapatkan
cefixime, karena tidak menunjukkan
tanda SIRS (minimal 2)
Rekomendasi kepada dokter :
cefixime diberikan selama 3 hari.
Setelah 3 hari, dilakukan evaluasi
tanda2 SIRS
19/5/12 Pasien mempunyai DM tipe II, tetapi
monitoring nilai GDP, GD2JPP kurangadekuat, sehingga tidak tahu apakah gula
darah pasien sudah terkontrol dengan baik
apa belum.
Dilakukan pemantauan nilai GDP,
GD2JPP minimal 3 hari sekali(Berdasarkan guideline, berapa kali? PR
CESA). Dan dilakukan pemeriksaan
HbA1C untuk melihat kepatuhan pasien
dalam pengobatan
Cont. DTPL
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Date Problem Action
20/5/12 Pasien dari awal MRS sudah terdiagnosa DM
tipe II, tetapi baru diberikan terapi Levemir 0-
0-4U pada tanggal 20 Mei 2012. Seharusnya
dari awal diberikan terapi insulin short acting
dan Levemir harus monitoring GDP.
21/5/12 Pasien mendapatkan terapi alupurinol dosis 3
x 100 mg. berdasarkan literatur (Ganiswara,
ed 4, P.221) alopurinol mengalami
biotransformasi oleh enzim xantin oksidase
menjadi aloxantin yang waktu paruhnya lebih
panjang daripada alupurinol, sehingga cukup
diberikan 1 x sehari.
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Pharmacists Care Plan
Pharmacotherapeutic
Goal
Monitoring
Parameter
Desired
Endpoint
Monitoring
Frequency
Date/ TimeMei
16 17 18 19 20
Mengatasi sesakTerjadinya
sesak
Berkurangnya
sesakTiap hari Sesak
Ronchi
Tidak ada
ronchi +/+
Mengatasi demam Suhu 36 - 37 C Tiap hari 37,8 C 37 C 36,4 C 36,5 C36,7 C
Mengontrol tekanan
darahTD
140/ 90
mmHg (JNC
VIII)
Tiap hari170/
100
200/
130
Mengontrol gula darahGDP 110 mg/ dL
(AACE)3 hari sekali
125 mg/
dL
GD2PP 140 mg/ dL
(AACE)
123 mg/
dL
HbA1c 6,5 mg/ dL
(AACE)Tiap 3 bulan
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Cont. PCP (1)
PharmacotherapeuticGoal
MonitoringParameter
DesiredEndpoint
MonitoringFrequency
Date/ Time
Mei
21 22 23 24
Mengatasi sesak Terjadinya sesakBerkurangnya
sesakTiap hari
Sesak
berkurang
Ronchi Tidak ada ronchi -/- +/+ +/+ -/-
Mengatasi demam Suhu 36 - 37 C Tiap hari 36,3 C 36,5 C 36,6 C 36 C
Mengontrol tekanan
darahTD
< 40/ 90 mmHg
(JNC VIII)Tiap hari 140/ 80 140/ 80 140/ 90
Mengontrol gula darahGDP < 110 mg/ dL(AACE)
3 hari sekali
GD2PP
-
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Cont. PCP (2)
PharmacotherapeuticGoal
MonitoringParameter
DesiredEndpoint
MonitoringFrequency
Date/ Time
Mei
16 17 18 19 20
Mengatasi nyeri dada Nyeri dadaBerkurangnya
nyeri dadaTiap hari -
Mengatasi batukBatuk
berdahak
Tidak terjadi
batuk
Tiap hari Batuk
Dahak dapat
keluarTiap hari Dahak
Mengontrol asam uratKadar asam
urat
4,5-8,5 mg/ dL
(Pagana &
Pagana)
3 kali
sehari13,1
Mengatasi infeksi Suhu 36 - 37 C Tiap hari 37,8 C 37 C 36,4 C 36,5 C 36,7 C
WBC4,5.103-
10.103/ mm3Berkala
11,9.103
/ mm3
11,9.103
/ mm3
RR 20X/ menit Tiap hari 18
Nadi 80-100 bpm Tiap hari 100 88 84 80 88
-
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58/59
Pharmacist Care Plan Monitoring
-
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Pharmacist Care Plan Monitoring
Worksheet
Hyperlink
http://d/%E2%80%A0mfk%202013%E2%80%A0/MFK%202013/Semester%202/PEMBEKALAN%20IFRS/BU%20ENDANG/Kompilasi%20Tugas%20Kelompok%202/TUGAS%20MODUL%205/Modul%205%20KIE%20kel%20ganjil%20MFK.dochttp://d/%E2%80%A0mfk%202013%E2%80%A0/MFK%202013/Semester%202/PEMBEKALAN%20IFRS/BU%20ENDANG/Kompilasi%20Tugas%20Kelompok%202/TUGAS%20MODUL%205/Modul%205%20KIE%20kel%20ganjil%20MFK.doc