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    This document records a patient's follow up after surgery over three days. On the first day, the patient complained of nausea and fatigue. The surgical wound was still wet and painful. On the second day, nausea and fatigue continued and the wound was still wet and painful. By the third day, nausea had subsided and fatigue was reduced, while the wound was no longer painful but still wet. Vital signs and test results like albumin and globulin levels were also recorded each day. Medications and therapies like IV fluids, antibiotics, analgesics and bed rest were continued during the three days.

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    This document records a patient's follow up after surgery over three days. On the first day, the patient complained of nausea and fatigue. The surgical wound was still wet and painful. On the second day, nausea and fatigue continued and the wound was still wet and painful. By the third day, nausea had subsided and fatigue was reduced, while the wound was no longer painful but still wet. Vital signs and test results like albumin and globulin levels were also recorded each day. Medications and therapies like IV fluids, antibiotics, analgesics and bed rest were continued during the three days.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    7 views1 page

    Follow

    Uploaded by

    ferry
    This document records a patient's follow up after surgery over three days. On the first day, the patient complained of nausea and fatigue. The surgical wound was still wet and painful. On the second day, nausea and fatigue continued and the wound was still wet and painful. By the third day, nausea had subsided and fatigue was reduced, while the wound was no longer painful but still wet. Vital signs and test results like albumin and globulin levels were also recorded each day. Medications and therapies like IV fluids, antibiotics, analgesics and bed rest were continued during the three days.

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    © All Rights Reserved
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    Follow Up Paska Operasi

    Tanggal
    Keterangan
    Keluhan
    Luka Operasi
    Tanda Vital
    -. Sensorium
    -. TD
    -. HR
    -. RR
    -. Temperatur
    Drainage
    Pemeriksaan
    Penunjang
    Terapi

    Hari I
    Tgl. 308-2005
    Mual - mual (+)
    Badan lemas (+)

    Hari II
    Tgl. 318-2005
    Mual - mual (+)
    Badan lemas (+)

    Hari III
    Tgl. 19-2005
    Mual - mual (-)
    Badan lemas (-)

    Nyeri (+)
    Masih basah

    Nyeri (+) >>>


    Masih basah

    Nyeri (-)
    Masih basah

    Compos Mentis
    100/70 mmHg
    88x/i
    20x/i
    37,5 O C

    Compos Mentis
    110/70 mmHg
    92x/i
    20x/i
    37,7 O C

    Compos Mentis
    110/70 mmHg
    88x/i
    20x/i
    37,5 O C

    Darah (+), 80 cc

    Darah (+), 50 cc

    Darah (-), Warna Kekuningan,


    50 cc

    Lab :
    Albumin : 1,8 gr/dl
    Globulin : 2,2 gr/dl
    Tirah baring
    Diet MI
    IVFD RL/D5% s/s 30 gtt/i
    Inf.Ciprofloxacin 200mg/12 jam
    Inf.Metronidazole 500mg/8 jam
    Inj.Tramadol 1 amp/8 jam
    Inj.Transamin 1 amp/8jam
    Inj.Ulsicur 1 amp/8 jam

    PA :
    Infiltrating Duct Ca Mammae +
    Reaktif Hyperplasia KGB
    Tirah baring
    Diet MII
    Inf.Plasbumin 25% 100cc/12 jam
    IVFD RL/D5% s/s 30 gtt/i
    Inf.Ciprofloxacin 200mg/12 jam
    Inf.Metronidazole 500mg/8 jam
    Inj.Tramadol 1 amp/8 jam
    Inj.Transamin 1 amp/8jam
    Inj.Ulsicur 1 amp/8 jam

    Tirah baring
    Diet MII
    Inf.Plasbumin 25% 100cc/12 jam
    IVFD RL/D5% s/s 30 gtt/i
    Inf.Ciprofloxacin 200mg/12jam
    Inf.Metronidazole 500mg/8 jam
    Inj.Tramadol 1 amp/8 jam
    Inj.Transamin 1 amp/8jam
    Inj.Ulsicur 1 amp/8 jam
    19

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