| No. |
Tanggal |
Profesi |
Nama |
ASSESMEN |
| 1 |
2024-03-24 08:03:45 |
Perawat |
shift elfi |
- S (SUBJECTIVE)
os mengatakan nyeri perut(+)
demam(+) - O (OBJECTIVE)
os tampak lemas hasil vital sign
TD:120/80mmhg
HR:82x/i
RR:21x/i
Temp:36 - A (ANALYST)
gangguan rasa nyaman - P (PLANNING)
kalaborasi dengan dr sppd
Therapy:Lanjut - I (INSTRUKSI)
|
| 2 |
2024-03-24 10:07:43 |
Dokter Umum |
dr fadilayana damanik |
- S (SUBJECTIVE)
demam(-)
manifestasi pendarahan(-)
mual(-)
muntah(-) - O (OBJECTIVE)
sens:cm
TD:120/80x/i
HR:82x/i
RR:20x/i
Temp:36 - A (ANALYST)
febris - P (PLANNING)
IVFD RL 30 gtt/i - I (INSTRUKSI)
cek darut / hari
|
| 3 |
2024-03-24 17:05:37 |
Perawat |
shift lenny |
- S (SUBJECTIVE)
os menggatakan demam (+) - O (OBJECTIVE)
os tampak lemas
TD :120/80X/I
HR :82x/i
RR:22x/i
T :36,5 - A (ANALYST)
gangguan rasa nyaman b/d gangguan pola aktivitas - P (PLANNING)
kolaborasi dengan dokter sppd - I (INSTRUKSI)
|
| 4 |
2024-03-25 08:00:00 |
Perawat |
jupe & shift elfi |
- S (SUBJECTIVE)
os mengatakan demam naik turun
nyeri perut (-) - O (OBJECTIVE)
os tampak lemas
hasil vital sign
Td: 110/70mmhg
Hr:80x/i
Rr: 20x/i
T: 36,5 - A (ANALYST)
gangguan pola aktifitas b/d lemas - P (PLANNING)
kolaborasi dr sppd - I (INSTRUKSI)
|
| 5 |
2024-03-25 16:30:44 |
Dokter Spesialis |
dr silvia bukit sppd |
- S (SUBJECTIVE)
Demam (-) - O (OBJECTIVE)
Td :120/80
- A (ANALYST)
Demam Dangue - P (PLANNING)
ACC PBJ
-Ranitidin 2x100
-Metoclopamide 3x1
-PCT k/p - I (INSTRUKSI)
|
