| No. |
Tanggal |
Profesi |
Nama |
ASSESMEN |
| 1 |
2024-05-16 22:00:43 |
Perawat |
shift lenny |
- S (SUBJECTIVE)
os tiba diruangan pukul 22.00wib dengan keluhan demam - O (OBJECTIVE)
os tampak lemas
Hr:98x/i
Rr:22x/i
T;39,5
BB:34kg - A (ANALYST)
gangguan rasa nyaman b/d gangguan pola aktifitas - P (PLANNING)
kolaborasi dr spA - I (INSTRUKSI)
|
| 2 |
2024-05-17 08:00:35 |
Perawat |
jupe & shift elfi |
- S (SUBJECTIVE)
ibu os mengatakan demam (+) - O (OBJECTIVE)
os tampak lemas
Hr:98x/i Rr:22x/i T;38,5 BB:36kg - A (ANALYST)
gangguan pola aktifitas b/d lemas - P (PLANNING)
kolaborasi dr spA - I (INSTRUKSI)
|
| 3 |
2024-05-17 11:00:34 |
Dokter Spesialis |
dr omar sazali SPA |
- S (SUBJECTIVE)
demam (+)
muntah (-)
sakit menelan (-) - O (OBJECTIVE)
sens cm
BB:36kg - A (ANALYST)
Fever Unspecified - P (PLANNING)
iufd Rl 34t/i makro
inj ceftriaxone 900mg/12jam/iv
pct drip540mg/4jam
inj ondansetron 8mg/8jam/iv
diet MB - I (INSTRUKSI)
cek malaria ulang saat menggigil
|
| 4 |
2024-05-17 17:00:07 |
Perawat |
shif leni n zurai |
- S (SUBJECTIVE)
ibu os mengatakan demam (+) - O (OBJECTIVE)
os tampak lemas
Hr:98x/i Rr:22x/i T;39,5 BB:36kg - A (ANALYST)
gangguan rasa nyaman b/d gangguan pola aktifitas - P (PLANNING)
kolaborasi dr spA - I (INSTRUKSI)
|
| 5 |
2024-05-18 08:00:07 |
Perawat |
shif leni n zurai |
- S (SUBJECTIVE)
ibu os mengatakan demam (+)mual (-) batuk (-) - O (OBJECTIVE)
os tampak lemas
Hr:98x/i Rr:22x/i T;39,5 BB:36kg - A (ANALYST)
gangguan rasa nyaman b/d gangguan pola aktifitas - P (PLANNING)
kolaborasi dr spA - I (INSTRUKSI)
|
| 6 |
2024-05-19 08:00:27 |
Perawat |
shift dede |
- S (SUBJECTIVE)
ibu os mengatakan demam naik trun
mual (-)
batuk (-)
nyeri ulu hati - O (OBJECTIVE)
os tampak lemas
Hr:98x/i Rr:22x/i T;38,5 BB:36kg - A (ANALYST)
gangguan pola aktifitas - P (PLANNING)
kolaborasi dr spA - I (INSTRUKSI)
|
| 7 |
2024-05-19 11:00:01 |
Dokter Umum |
dr fadilayana damanik |
- S (SUBJECTIVE)
batuk (+)
mual (-)
muntah (-)
demam (+) sore ini - O (OBJECTIVE)
sens cm
Hr:98x/i Rr:22x/i T;39,5 BB:36kg - A (ANALYST)
dengue fever - P (PLANNING)
konsul via telpon dr zahara spA
iufd Rl 34tpm mac
inj ceftriaxone 850mg/12jam
drip pct 540mg/4jam
inj ondansetron aff - I (INSTRUKSI)
cek darut /hari
|
| 8 |
2024-05-19 17:00:01 |
Perawat |
shift elfi |
- S (SUBJECTIVE)
ibu os mengatakan demam (+)
batuk (+) - O (OBJECTIVE)
os tampak lemas Hr:98x/i Rr:22x/i T;39,5 BB:36kg - A (ANALYST)
gangguan rasa nyaman - P (PLANNING)
therapi lanjut - I (INSTRUKSI)
|
| 9 |
2024-05-20 08:00:36 |
Perawat |
jupe & shift dede |
- S (SUBJECTIVE)
ibu os mengatakan demam naik trun mual (-) batuk (+) - O (OBJECTIVE)
os tampak tenang Hr:98x/i Rr:22x/i T;36,5,5 BB:36kg - A (ANALYST)
gangguan pola aktifitas - P (PLANNING)
kolaborasi dr spA - I (INSTRUKSI)
|
| 10 |
2024-05-20 19:09:01 |
Perawat |
RI-Kelas II sif siska & dkk |
- S (SUBJECTIVE)
os mengatakan demam(-)
mual(-) muntah(-) - O (OBJECTIVE)
os tampak tenang
HR:81x/i
RR:21x/i
Temp:36,5
BB:34 kg - A (ANALYST)
gangguan rasa nyaman - P (PLANNING)
kalaborasi dengan dokter SpA
Therapy Lanjut - I (INSTRUKSI)
|
| 11 |
2024-05-21 10:29:18 |
Perawat |
RI-Kelas II kel rani dkk |
- S (SUBJECTIVE)
os mengatakan demam sudah turun mual (-) - O (OBJECTIVE)
os tampak tenang dan beristirahat
HR:98x/i
RR:22x/i
T:36,5
BB:34 kg - A (ANALYST)
sebagian masalah teratasi therapy di lanjutkan - P (PLANNING)
Pantau TTV
kolaborasi dengan dr spA - I (INSTRUKSI)
|
| 12 |
2024-05-21 11:32:42 |
Dokter Spesialis |
RI-Kelas I |
- S (SUBJECTIVE)
demam (-) mual (-)muntah (-) - O (OBJECTIVE)
sens :cm - A (ANALYST)
dx DHF - P (PLANNING)
cefixim2x100
pct 3x1
imbost 1x1 - I (INSTRUKSI)
|
