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    Lampiran Follow Up Pasien: Heart Rate (X/MNT) Respiration Rate (X/MNT)

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    Jesse Estrada
    This document records the daily follow up of a patient's condition over a 10 day period after surgery. It includes subjective reports of symptoms, objective measurements of vital signs and wound status. It also documents treatments administered and assessments of the patient's status. The patient's condition improved over time, with decreasing pain levels, drainage from the wound, and normalization of vital signs. Various medications and one blood transfusion were provided during the recovery period. Laboratory test results show improvement in hematological values after the transfusion.

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    Lampiran Follow Up Pasien: Heart Rate (X/MNT) Respiration Rate (X/MNT)

    Uploaded by

    Jesse Estrada
    8 views4 pages
    This document records the daily follow up of a patient's condition over a 10 day period after surgery. It includes subjective reports of symptoms, objective measurements of vital signs and wound status. It also documents treatments administered and assessments of the patient's status. The patient's condition improved over time, with decreasing pain levels, drainage from the wound, and normalization of vital signs. Various medications and one blood transfusion were provided during the recovery period. Laboratory test results show improvement in hematological values after the transfusion.

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    lapsus

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    Lampiran Lapsus

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    This document records the daily follow up of a patient's condition over a 10 day period after surgery. It includes subjective reports of symptoms, objective measurements of vital signs and wound status. It also documents treatments administered and assessments of the patient's status. The patient's condition improved over time, with decreasing pain levels, drainage from the wound, and normalization of vital signs. Various medications and one blood transfusion were provided during the recovery period. Laboratory test results show improvement in hematological values after the transfusion.

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    8 views4 pages

    Lampiran Follow Up Pasien: Heart Rate (X/MNT) Respiration Rate (X/MNT)

    Uploaded by

    Jesse Estrada
    This document records the daily follow up of a patient's condition over a 10 day period after surgery. It includes subjective reports of symptoms, objective measurements of vital signs and wound status. It also documents treatments administered and assessments of the patient's status. The patient's condition improved over time, with decreasing pain levels, drainage from the wound, and normalization of vital signs. Various medications and one blood transfusion were provided during the recovery period. Laboratory test results show improvement in hematological values after the transfusion.

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    of 4

    LAMPIRAN

    FOLLOW UP PASIEN
    Follow up
    Subjektif
    Pusing
    Nyeri perut post operasi
    Batuk berdahak
    Objektif
    Heart Rate (x/mnt)
    Respiration Rate (x/mnt)
    o
    Suhu ( C)
    Tekanan darah

    14
    Oktober
    2014

    15
    Oktober
    2014

    16
    Oktober
    2014

    17
    Oktober
    2014

    18
    Oktober
    2014

    19
    Oktober
    2014

    20
    Oktober
    2014

    21
    Oktober
    2014

    22
    Oktober
    2014

    23
    Oktober
    2014

    +
    +
    -

    +
    +
    -

    +
    -

    100
    20
    36,3
    120/180

    80
    20
    36,5
    120/80
    Ca (+)
    Si (-)
    C/P
    Dbn
    Cembung
    , BU(+),
    Luka
    post op
    (+)
    akral
    hangat,
    CRT<2

    84
    20
    36,3
    130/80
    Ca (-)
    Si (-)
    C/P
    Dbn
    Cembung,
    BU(+),
    Luka post
    op (+)

    82
    20
    36,4
    120/80
    Ca (-)
    Si(-)
    C/P
    Dbn
    Cembung,
    BU(+),
    Luka post
    op (+)

    84
    20
    36,4
    130/90
    Ca (-)
    Si(-)
    C/P
    Dbn
    Cembung,
    BU(+), Luka
    post op (+)

    80
    20
    36,6
    120/80

    84
    20
    36
    120/70

    88
    20
    36,8
    120/80

    84
    20
    36,4
    120/80

    84
    20
    36,4
    120/80

    Ca (-)
    Si (-)
    Ca (-)
    Si (-)
    Cembung,
    BU(+), Luka
    post op (+)

    Ca (-)
    Si (-)
    Ca (-)
    Si (-)
    Cembung,
    BU(+), Luka
    post op (+)

    Ca (-)
    Si (-)
    Ca (-)
    Si (-)
    Cembung,
    BU(+), Luka
    post op (+)

    Ca (-)
    Si (-)
    Ca (-)
    Si (-)
    Cembung,
    BU(+), Luka
    post op (+)

    Ca (-)
    Si (-)
    Ca (-)
    Si (-)
    Cembung,
    BU(+),Luka
    post op (+)

    akral
    hangat,

    akral
    hangat,

    akral
    hangat,

    akral
    hangat,

    Kepala

    Ca (+) Si (-)

    Thorak

    C/P
    Dbn

    Abdomen

    Ekstremitas

    14 Oktober 2014
    15 Oktober 2014
    16 Oktober 2014
    17 Oktober 2014
    18 Oktober 2014
    19 Oktober 2014
    20 Oktober 2014
    21 Oktober 2014

    Cembung,
    BU(+)
    Luka post
    op (+)
    Akral
    hangat,
    CRT<2

    akral
    akral
    akral
    akral
    hangat,
    hangat,
    hangat,
    hangat,
    CRT<2
    CRT<2
    CRT<2
    STATUS GINEKOLOGI & PRODUKSI DRAIN
    PPV (+), produksi drain (+) 200cc
    PPV (+), produksi drain (+) 200cc
    PPV (+), produksi drain (+) 150cc
    PPV (+) <<, produksi drain (+) 150cc
    PPV (+) <<, produksi drain (+) 100cc
    PPV (-),produksi drain (+) 50cc
    PPV (-), produksi drain (+) 50cc
    PPV (-), produksi drain (+) 40cc

    22 Oktober 2014
    23 Oktober 2014

    PPV (-), produksi drain (+) 10cc


    PPV (-),produksi drain (-)

    PLANING

    Planing

    14

    15

    16

    Inf. RL

    Inj. Ceftriaxone 2 X 1

    Injj.Ketorolac 3 x 30 mg

    Injj.Kalnex 3 x 500 mg

    Transfusi darah

    17

    18

    19

    20

    21

    22

    23

    As.mefenamat 3x1

    Cefadroxile 2x1

    Sf 1x1

    Sylex syr 3 x 1 C

    Metronidazole 3 x
    500mg

    Cefat 2 x 500mg

    Kalnex 3 x 500mg

    ASSESMENT
    14 Oktober
    2014

    15 Oktober 2014

    16 Oktober
    2014

    17 Oktober
    2014

    18 Oktober
    2014

    19 Oktober
    2014

    20 Oktober
    2014

    21 Oktober
    2014

    22 Oktober
    2014

    23 Oktober
    2014

    P4A0 post
    laparotomi H0
    a/i KET

    P4A0 post
    laparotomi H1 a/i
    KET

    P4A0 post
    laparotomi H2
    a/i KET

    P4A0 post
    laparotomi H3
    a/i KET

    P4A0 post
    laparotomi H4
    a/i KET

    P4A0 post
    laparotomi H5
    a/i KET

    P4A0 post
    laparotomi H6
    a/i KET

    P4A0 post
    laparotomi H7
    a/i KET

    P4A0 post
    laparotomi H8
    a/i KET

    P4A0 post
    laparotomi H9
    a/i KET

    Hasil Laboratorium
    13 Oktober
    2014
    (pre transfusi)

    13 Oktober
    2014
    (post transfusi)

    21 Oktober
    2014

    5,0

    9,1

    611,3

    8.800

    18.340

    10.900

    Trombosit (uL)

    130.000

    241.000

    268.000

    Hematokrit (%)

    15

    27,9

    34,5

    Hemoglobin (g/dL)
    Leukosit (uL)

    Ureum
    Kreatinin

    1,45

    GDS

    245

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