| No. |
Tanggal |
Profesi |
Nama |
ASSESMEN |
| 1 |
2024-05-15 11:30:14 |
Perawat |
jupe dan shift lenny |
- S (SUBJECTIVE)
os datang dari igd ke kls 2 pukul 11.30wib dengan keluhan nyeri ulu hati (+) - O (OBJECTIVE)
os tampak lemas
hasil vital sign :
Td :160/100mmhg
hr :80x/i
Rr:20x/i
T:36,5 - A (ANALYST)
gangguan pola katifitas b/d lemas d/d nyeri ulu hTI
- P (PLANNING)
Konsul dr sppd - I (INSTRUKSI)
|
| 2 |
2024-05-15 14:00:58 |
Dokter Spesialis |
dr arief kurniawan.Sp.PD |
- S (SUBJECTIVE)
nyeri ulu hati (+)
demam (-) - O (OBJECTIVE)
sens cm - A (ANALYST)
gastrities
cholistitities
DM - P (PLANNING)
inj keterolac 1amp/8jam
candesartan 1x8mg
sucralfat 3xc1
metformin 2x500mg - I (INSTRUKSI)
cek gdp & Gd2jam pp
usg abdomen
|
| 3 |
2024-05-15 20:44:47 |
Perawat |
RI-Kelas II kel rani dkk |
- S (SUBJECTIVE)
os mengatakan nyeri ulu hati(+)mual(-) lemas(+) - O (OBJECTIVE)
os tampak beristirahat
TD:160/100mmhg
HR:84x/i
RR;20x/i
T:36 - A (ANALYST)
gangguan pola aktivitas berhubungan dengan rasa nyeri - P (PLANNING)
pantau TTV
kolaborasi dengan dr sppd - I (INSTRUKSI)
|
| 4 |
2024-05-16 08:00:29 |
Perawat |
jupe & shift elfi |
- S (SUBJECTIVE)
os mengatakan nyeri ulu hati(+)
mual(-) muntah (-) - O (OBJECTIVE)
os tampak lemas
hasil vital sign :
Td :160/100mmhg
hr :80x/i
Rr:20x/i
T:36,5 - A (ANALYST)
gangguan pola aktifitas b/d lemas d/d nyeri ulu hTI - P (PLANNING)
Konsul dr sppd
- I (INSTRUKSI)
|
| 5 |
2024-05-16 14:00:39 |
Dokter Spesialis |
dr arief kurniawan.Sp.PD |
- S (SUBJECTIVE)
nyeri ulu hati berkurang
- O (OBJECTIVE)
sens cm - A (ANALYST)
gastrities
choletistities
DM - P (PLANNING)
metformin 1x500mg
therapi lanjut - I (INSTRUKSI)
usg abdomen besok
|
| 6 |
2024-05-16 17:05:10 |
Perawat |
shif leni n zurai |
- S (SUBJECTIVE)
os mengatakan nyeri ulu hati (+)mual (+)muntah (-) - O (OBJECTIVE)
os tampak lemas
TD :110/70mmhg
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)
|
| 7 |
2024-05-17 08:00:24 |
Dokter Spesialis |
dr Hendri M.Kes,M.Ked,SpPD |
- S (SUBJECTIVE)
nyeri perut
tangan kaki kebas - O (OBJECTIVE)
sens cm
- A (ANALYST)
abdominal pain
cholistitities - P (PLANNING)
metformine 2x1
gabapentine 1x1
lansoprazole 2x30mg
candesartan 1x8mg
sucralfat 3x1 - I (INSTRUKSI)
usg abdomen
|
| 8 |
2024-05-17 08:00:57 |
Perawat |
jupe & shift elfi |
- S (SUBJECTIVE)
nyeri ulu hati berkurang
- O (OBJECTIVE)
os tampak beristirahat
TD:160/100mmhg HR:84x/i RR;20x/i T:36 - A (ANALYST)
gangguan pola aktifitas - P (PLANNING)
Konsul dr sppd
- I (INSTRUKSI)
|
