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Vertigo

In: Science

Submitted By berliany
Words 461
Pages 2
BAB IV
PEMBAHASAN
Telah dilaporkan sebuah kasus dari seorang pasien perempuan usia 2 tahun yang masuk ke bangsal Anak RSUD Palembang Bari pada tanggal 19 April 2014. Dari anamnesis didapatkan keluhan utama pasien yaitu bab cair sejak 2 hari SMRS. Riwayat perjalanan penyakit , BAB cair sejak 2 hari SMRS, frekuensi ±10x, air lebih banyak dari ampas, warna kuning, darah (-), lendir (-). Muntah (+) 4x isi apa yang dimakan. Demam (-) , batuk (-) , pilek (-). Pasien tampak haus (+) , BAK biasa, dari anamnesis yang didapatkan pasien mengalami diare akut.
Pada pemeriksaan fisik didapatkan ubun- ubun cekung , mata cekung, air mata masih ada, turgor kulit kembali lambat dan pasien sangat merasa haus. Dari pemeriksaan fisik tersebut menandakan pasien mengalami dehidrasi ringan – sedang.
Pada pemeriksaan laboratorium didapatkan leukosit 8.500/ ul, hal ini menandakan diare akut yang dialami pasien bukan disebabkan oleh infeksi bakteri dan kemungkinan disebabkan oleh virus. Pada pemeriksaan feaces didapatkan Eritrosit : 0-1,leukosit: 1-2 , ditemukannya eritrosit pada feces biasanya bersasal dari anus atau rektum dikarenakan adanya lesi. Untuk leukosit feses 1-2 dikatakan tidak bermakna.
Terapi yang diberikan pada pasien ini pada tanggal 19 april 2014 adalah IVFD RL gtt 25x/m (makro) selama 4 jam , dilanjutkan dengan gtt 10x/m, Oralit diberikan 100cc setiap BAB, Zink 1x20mg. Pada dehidrasi ringan sedang seharusnya diberikan rehidrasi secara oral saja yaitu oralit 75cc/kggbb/selama 4 jam, namun pada pasien ini mengalami bab cair dan muntah profuse sehingga rehidrasi diberikan secara intravena dan oral, yang bertujuan untuk mengganti previous water losses dan mencegah terjadinya dehidrasi berat (on going water losses) .
Pada tanggal 21 april 2014 terapi yang diberikan IVFD Kaen 3A gtt X/m (makro), Oralit 100cc/BAB, Zink 1x20mg, Pemberian rehidrasi cairan melalu intravena seharusnya tidak diperlukan lagi karena keadaan pasien sudah membaik , tidak ada tanda dehidrasi lagi , bab cair dan muntah sudah tidak profuse , anak mau minum oralit dan dapat makan seperti biasa. Oralit yang diberikan pada pasien tersebut adalah sebanyak 10cc-20cc/kgbb/BAB. Pemberian tablet zink pada pasien ini bertujuan untuk mengurangi lama dan beratnya diare serta mengurangi kekambuhan diare pada hari- hari mendatang, tablet zink diberikan selama 10-14 hari .
Pada pasien dengan diare penatalaksanaan selanjutnya yang harus dilakukan adalah memberikan nutrisi yang baik dan bergizi kepada anak, makanan rendah serat serta memberikan edukasi kepada keluarga pasien , edukasi yang diberikan berupa selalu menjaga kebersihan anak,buang air besar pada tempatnya , mengajari ibu membuat dan memberikan oralit kepada anak, dan memberitahu meskipun pasien telah pulang kerumah , tablet zink tetap harus diberikan selama 10-14 hari.
Penderita pada tanggal 24 April 2014 diperbolehkan untuk pulang , indikasi pasien diperbolehkan pulang adalah tidak ditemukan lagi tanda- tanda dehidrasi, ibu dapat memberikan oralit kepada anak dirumah, anak mau minum oralit , anak mau makan dan minum seperti biasa , serta anak tidak mengalami BAB cair maupun muntah lagi.

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