LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)

7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)

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LAPORAN JAGA

TANGGAL 01 DESEMBER 2015

Disusun oleh:

Astri Flun

Asri Ali!



" #$ #%entits

" N& : Tn$ S

" 'si : (2 Thun

" Run)n : *en%n ##



" An&nesis se+r uton&nesis ,% tn))l

0-.12.2015 ,u/ul 1($-0 #B$

"eluhn 't& : Perut /e&un) se3/ 5 hri 4n) llu$

" eluhn T&hn:



RPS :

" Psien %tn) %en)n /eluhn ,erut /e&un) se3/ 5hri 4n) llu %ii/uti rs n4eri ,% ulu hti n4eri se,erti

%itusu/6tusu/ %n n4eri %irs/n hiln) ti&ul n4eri is

&en3lr /e ,erut /nn %n /iri ts$ Psien &en)/u

se&en3/ ,erutn4 /e&un) i &ers &ul %n &unth758 erisi +irn enin) %rh 96 %l& /urun ;/tu 2(

3&$

" Psien 3u) ti%/ is un) n)in %n BAB se3/ 5 hri

4n) llu$ N&un st %i RS$Polri setelh ,sien%ieri/n !leet ene& ,sien BAB +ir ;rn hit& 18$



" 2 hri SMRS ,sien erot /e /lini/ 2( 3& %n

%ieri/n &etroni%<ole %n ,ro&) n&un ti%/ %

,eri/n llu ,sien /e #GD RS$Polri

" BA nor&l !re/uensi (658 sehri %rh 96

" St %i RS$Polri ,sien %i,sn) NGT +irn er;rn

hi3u /e+o/ltn = 500++$ >ri r;t /e - %i RS$Polri

,sien &en)eluh/n ses/ n!s %n %e&& suhu

%iu/ur -?@ +⁰



" RPD

" >i,ertensi %isn)/l

" Dietes &elitus %isn)/l

" Aller)i %isn)/l

" Ri;4t tru& ,% ,erut %isn)/l



Pe&eri/sn Fisi/

" ' : T&,/ s/it se%n)

" es%rn : *o&,os &entis

" TT

" TD : 1(0.@0 &&>)" N : @58 .&enit

" RR : 228 .&enit

" Suhu : -5 *



Sttus Generlis

" e,l : %e!or&its 96 nor&o+he,li

" Mt : on3un)tiC Ane&is 96.6 S/ler #/teri/ 96.6

" Leher : Pe&esrn GB 96

" Thor8

" Pul&o# : ,er)er/n %% si&etris %l& /e%n sttis %n %in&is$

P : !re&itus t/til Co/l si&etris ilterl

P : sonor ,% /e%u l,n) ,ru

A : sur n!s Cesi/uler Rhon+i 6.6 ;hee<in) 6.6

" *or : s1s2 re)uler )llo, 96 &ur&ur 96



" A%o&en# : Distensi si/tri/ 96 %r& +ontour 96 %r& stei!un) 96

P: NT 9 R' %n L' %e!ns &us/ulr 96 &ss 96

P: N 9 R' %n L' hi,erti&,ni %i /e ( /u%rn %o&en

A: B' 9 le&h &etli+ soun% 96

" E8tre&its : /rl hn)t *RT 2 %eti/





Re+tl tou+her

" Tonus s,hin+ter ni i/

" A&,ull re+ti ti%/ /ol,s

" Mu/os li+in

" Mss 96" N4eri te/n 96

" Prostt : rh 3& 12 /onsistensi /en4l ,er&u/n

rt ,ole ts ter sul+us &e%inus ter$

" >n%s+oen: !eses 9 %rh 96 len%ir 96



T)l 01.12. 2015riel Te&un Nili Nor&l

>e&tolo)i

> 1$1).%l 1261( ).%l

Leu/osit 15$000 u.l 5000610$000 u.l

>t (5H -?6(-H

Tro&osit 2I-$000 .ul 150$0006(00$000.ul

i&i lini/

Ntriu& 1-5 1-561(5 &&ol .l

liu& -I -$@ 5$0 &&ol . l

*hlori% 102 I@ 10 &&ol . l

GDS 125



T)l 0-.12.2015

riel Te&un Nili Nor&l

>e&tolo)i

> 15$).%l 1261( ).%l

Leu/osit 10$@00 u.l 5000610$000 u.l

>t (H -?6(-H

Tro&osit 2(@$000 .ul 150$0006

(00$000.ul

riel Te&un Nili Nor&l

SGOT 1?$0 -? '.L

SGPT 10$@ (0 '.L

*holestrol totl 1-5 200 &).%l

tri)liseri% @- 200 &).%l

Renl Fun)si test

'reu& (1 10650 &).%l

*retinin 1$0 05 15 &).%l

As& urt 5$- -( ?0 &).%l



T)l 0-.12.2015

ANALISA GAS

DARAH

,> ?- ?-5 ?(5

,*O2 2I -5 -(&&>)

Po2 I0 @5 I5 &&>)

O2 stursi I? @5 I5H

>*O- 1 21 25 &&ol.L

Bse E8+ess 6? 62 6 25 &&ol.L

SB* 1I 22 2 &&ol.L

Totl *O2 1? 21 2? &&ol.L

SBE 6@ 62( 6 2- &&ol.L







esn :

" G&rn &ss %uo%enu&

" Diltsi usus esr %n usus /e+il s&,i /e%istl %n

%iserti ,en4e&,itn %erh re+tu& 9+olitis



Di)nosis

" Prtil ileus ostru/ti! e$+ &ss %uo%enu&



Pentl/snn

" onsul %r$it S,$B

" Psn) NGT %n ,us

" #FD RL : A&ino!lui% K 2 : 1

" #n3 +e!tri8one 1 8 2)r

" #n3 on%nsentron 9/.,

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LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)