contoh asesment digestiv
DESCRIPTION
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ROMSEN SAMUEL SINAGA/LK/29
POST LAPAROTOMI ec PERITONITIS
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ANAMNESIS
Keluhan utama : nyeri perut pada seluruh lapangan perutTelaah : hal ini telah dialami os ± 3 hari ini, os merasa perut keras seperti memapan, os juga mengeluhkan perutnya kembung, mual (+), muntah (-), demam (-), BAB (-) tidak normal, BAK tidak lancar, os juga merasa sesak saat bernafas
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STATUS PRESENS
• Sensorium : Compos mentis• TD : 100/60 mmHg• HR : 80 x/i• RR : 20 x/i• Temp : 37,1
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STATUS GENERALISATA
• KepalaMata : Conj.Palp.Inf.Anemis(-/-),pupil isokor,RC(+/+),ikterik(-/-)Hidung : tidak dijumpai kelainanMulut : tidak dijumpai kelainanLeher : tidak dijumpai kelainanThoraks : tidak dijumpai kelainanAbdomen : keras seperti memapanExtremitas : tidak dijumpai kelainan
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STATUS LOKALISATA
Abdomen• Inspeksi : post laparatomy • Palpasi : tidak dilakukan pemeriksaan• Perkusi : timpani• Auskultasi: peristaltik (+) lemah• DRE : perineum normal, tonus spingter ani
ketat,mukosa licin,ampula recti kosong,nyeri(-), sarung tangan : feses(-),darah(-),lendir(-)
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Foto Klinis
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TREATMENT
• IVFD asering-dextrose = 3:1• Inj. Ketorolak 30 mg/8jam• Inj. Meropenem 1gr/8jam• Drip metronidazole 500 mg/8jam• Inj. Omeprazole 40mg/12jam• Inj. Ketorolac 30 mg/8jam• PCT drip 1 fls/8jam• RHZE • Diet m1
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RENCANA
• Cek albumin