Summery of Initial Planning

Clue and Cue Problem List

Data Base Diagnosis Diagnosis Therapy Monitoring Education
Laki-laki 23th -anemis 1. Syok USG due - Terapi - Vital sign - Control
KU : nyeri perut - hiperventilasi hipovolemic et to FAST cairan - Diuresis teratur
kuadran kiri - nyeri perut causa ( Focused kristaloid - Perawatan
atas menjalar kuadran kiri haemorrhagic Abdomen - Pemasanga luka
ke bahu kiri atas menjalar with n NGT dan 3. Higienitas
Ax : ke bahu kiri 2. Trauma Sonograph kateter 4. Asupan
- 1 jam yll -hipotensi Abdomen y for - Antibiotika gizi
terkena -takikardi trauma ) + H2
tendangan di - syncope blocker
perut region -nausea - Transfuse
kuadran -vomit darah bila
sinistra atas perlu
- Pingsan, PRC
nausea, - Laparotomi
vomiting
PD :
1. Primary
survey :
ABCDE
2. Secondary
Survey :
- BP : 70/40
mmHg,
pulse rate
120x/mnt,
RR
28x/mnt,
akral
dingin, CRT
4dtk
- Kepala :
konjungtiv
a anemis
- Thorax :
dbN
- Abdomen :
region
kuadran
sinistra
 atas
tampak
jejas dan
tenderness
- Ekstremita
s:
eksternal
bleeding
(-)