Morning Report Bedah-fatimeh
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Transcript of Morning Report Bedah-fatimeh
7/23/2019 Morning Report Bedah-fatimeh
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MORNING REPORTRabu, 22 Juli 2015
DM Fatim
DM Imov
DM Tya
7/23/2019 Morning Report Bedah-fatimeh
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Dokter Jaga
1. dr. Bimanda
2. dr. Safnaz
Perawat Jaga3. Perawat Widya
. Perawat !ia
". Perawat #rie
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1. Identitas Pasien
$ama % Tn. Sami&an
'm(r % ) ta*(n
#+amat % ,(ra* -a+ong Banga+ Sari$o. /egitrai % )0.).2
Stat( % 'm(m
Tangga+ datang % 22 J(+i 2)1" Jam -eadian J-4 % 1.3)
Jam Datang JD4 % 1".3)
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• Subjektif
-' % Pen(r(nan keadaran
M5I % Paien mengendarai SPM dan6erta6rakan dengan mo6i+. 7e+m 849
ke:a+a ter6ent(r a:a+ 849 m(nta* 849m(a+ 849 :(ing 849 :ingan ;4. J- 13.)) JD 1".3)
/PD % e:i+e:i ;4
/P5 % nor e:*inamin ma+eat ;49 ,TM ;49Diaze:am ;4
/P-% <:i+e:i ke+(arga ;4
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• Pemeriksaan Fisik
Primary Survey
# % Patent
B % 2 ka+i :er menit
, % TD % 12=>=1 mm7g9 nadi % =3 ka+i :er menit
D % ?,S 3;";
< % m(+ti:+e v. a6rai9 ,5/
• Assesment
;v(+n( a6rai regio @ronta+i diameter 3A"A)9" m
;v(+n( a6rai regio zygoma
;,5/
• Planning
56ervai :aien 2 am
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• Secondary Survey 1C%3)
Stat( genera+i
-' % ,(k(:-e % # P '
TD % 12)>C) mm7g
$adi % 00 ka+i :er menit
// % 2) ka+i :er menit
TaA % 39C deraat ,
-!>! % a>i>>dE;>;>;>;
T*oraA %; Simetri9 retraki ;>;
; ,or % S1S2 t(ngga+
; P(+mo % ve 8>89 r*onki ;>;9 w*eezing ;>;
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#6domen %
F+at9 6iing (( 84 da+am 6ata norma+9
tim:ani9 :ekak *e:ar9 oe:e+<At %
#7 8 8 5< ; ;
8 8 ; ;
• Status Lokalis
/egio % MaAi+o@aia+
I % . a6rai9 e:*a+ *ematom r. tem:ora+
P % nyeri ;49 kre:itai ;4
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• Assesment
;M(+ti:+e (+n( #6rai regio @ronta+idan regio zygoma
; ,e:*a+ *ematom region tem:ora+
• Planning
/awat !(ka
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2. Identitas Pasien
$ama % an. Dani
'm(r % = ta*(n
#+amat % d((n #(ng /T "> /W 1$o. /egitrai % )0.).C)
Stat( % BPJS PBI
Tangga+ datang % 22 J(+i 2)1"
Jam Datang JD4 % 1.3)
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• S> -'% $yeri Per(t
/:% Paien menge+(* nyeri :er(t eak
C *ari yg +a+(9 tidak 6ia B#B Seak " *ariyang +a+(9 tidak 6ia kent(t eak 1 *ariyang +a+(9 m(a+ ;49 M(nta* 84.
/:d% ;
/P5% ;
/P-% ;
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Stat( genera+i
-' % ,(k(:
-e % # P ' TD % 13)>C) mm7g
$adi % 12= ka+i :er menit
// % 32 ka+i :er menit
TaA % 309C deraat ,
-!>! % a>i>>dE;>;>;>;
T*oraA %
; Simetri9 retraki ;>;; ,or % S1S2 t(ngga+
; P(+mo % ve 8>89 r*onki ;>;9 w*eezing ;>;
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#6domen %
F+at9 6iing (( 84 da+am 6ata norma+9 tim:ani9:ekak *e:ar 849 oe:e+9 nyeri tekan e+(r(*
+a:ang :er(t<At %
#7 8 8 5< ; ;
8 8 ; ;
• Status Lokalis
/egio % a6domen
I% at
#% B' 84
P% Tym:ani
P% oe:e+9 nyeri tekan 84
/T% TS# 849 $yeri 84
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• Assesment
#:endiiti
• Planning
/! 12") >2am
e@tazidime 3A C") mg
ranitidine 2A3) mg
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3. Identitas Pasien
$ama % Tn. J(madi
'm(r % " ta*(n
#+amat % Pand(mman gg I no. 3=9 Jem6er
$o. /egitrai % )0.).C"
Stat( % BPJS PBI
Tangga+ datang % 22 J(+i 2)1" Jam keadian % 10.3)
Jam Datang JD4 % 2).3)
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• S> -'% !(ka di tangan
M5I% :aien mengendarai SPM dita6rak SPM
+ain dari ara* yang 6er+awanan9 :aien at(* dan tangannya ter+inda 6an SPM +ain.M(a+ ;49 M(nta* ;49 :ingan ;49 keang ;497e+m 84. Tangan mai* 6ia digerakkan
e:erti menggenggam dan mem6(ka tangan J-% 10.3)
JD% 2).3)
/PD% e:i+e:y ;4
/P5 % nor e:*inamin ma+eat ;49 ,TM ;49
Diaze:am ;4
/P- % <:i+e:i ke+(arga ;4
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• Pemeriksaan Fisik
Primary Survey 2.3
# % Patent
B % S:ontan9 2 ka+i :er menit
, % TD % 1)>C) mm7g9 nadi % = ka+i :er menit
D % ?,S ;";
< % (+n( +aerai region man( deAtra
• Assesment
v(+n( +aerai reg. Man( DeAtra
• Planning
de6ridement
Pro *eting +aerai
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!. Identitas Pasien
$ama % Tn. M(o
'm(r % " ta*(n
#+amat % wonokoyo9 /T 1> /W 3-o:ongan9 Sit(6ondo
$o. /egitrai % )0.).1
Stat( % BPJS PBI Tangga+ datang %22 J(+i 2)1"
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• Subjektif
-' % tidak 6ia kening
/PS% Paien menge+(* B#- tidak +anareak 12 *ari yg +a+(9 B#- dara* 84
edikit9 eak 3 t* yg +a+( B#-6era6ang9 kadang tidak 6ia ke+(ar.Paien r((kan dari r it(6ondo
/PD % reteni (rin 3 t* yang +a+( e.. BP7/P- % ;
/P5 % riwayat :emaangan kateter
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• "bjektif
-' % (k(:-e % #+ert
TD % 1))>C) mm7g
7/ % 0 A>menit9 k(at angkat9 reg(+er
// % 2) A>menit TaA % 3C90 deraat ,
->! % a>i>>dE;>;>;>;
T*o % imetri9 retraki ;4
>: E SIS2 t(ngga+9 ve 8>89 r* ;>;9 w* ;>;#6d % at9 B' 84 $9 tim:ani9 oe:e+9 nyeri tekan 84
<At % #7 8>89 5< ;>;
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Stat( 'ro+ogi%
/. F+ank% F+ank tet ;>;9 :a+:ai 6iman(a+% $yeri
8>;9 maa ;>;/. S(:ra:(6ik% F+at9 Tym:ani9 P(ngi
S(:ra:(6ik 84
/. ?enita+ia <At% Dara* 849 P( ;4
• Assesment
/eteni (rin e.. Strikt(r (retra
• Planning
Trokar ytotomi
'retrogram 1 mingg( kem(dian
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#$%I&A'ASI(