4392 - Laporan Pembelajaran Ikk Lengkap

LAPORAN PEMBELAJARAN
ILMU KEDOKTERAN KLINIK (IKK)

DI RSD BALUNG-JEMBER
Oleh:
Kelompok IKK Putaran Satu (1)
BAGIAN ILMU KEDOKTERAN KLINIK

FAKULTAS KEDOKTERAN GIGI
UNIVERSITAS JEMBER
2018
Anggota kelompok IKK putaran 1:
Kelompok A1
No. NIM NAMA
1. 121611101014 Hayyu Safira Fuadillah
2. 131611101059 Muhammad Maulana Akbari
3. 121611101074 Bimasakti Wahyu Irianto
4. 081611101013 Adilah Novarani Dwipayanti
5. 131611101037 Tadjul Arifin
Kelompok A2
No. NIM NAMA
1. 121611101029 Farah Alvira
2. 121611101055 Elizabeth Luna Kania Anindita
3. 111611101009 Rhanifda Amvitasari
4. 121611101087 A.A. Istri Puspita Sari Dewi
5. 131611101093 Kharishah Muslihah
Kelompok B1
No. NIM NAMA
1. 121611101034 Cintya Rizki Novianti
2. 121611101065 Annasa Nur Hidayah
3. 121611101002 Trianike Nor Aini
4. 131611101096 Usnida Mubarokah
5. 121611101069 Astinia Widyastuti
Kelompok B2
No. NIM NAMA
1. 121611101043 Arum Kartika Dewi
2. 121611101059 Asti Widaryati
3. 121611101079 Puspandaru Nur Iman Fadlil
4. 131611101062 Nadia Kurniasih
Kelompok C1
No. NIM NAMA
1. 121611101045 Puspita Firdausa
2. 121611101071 Rachel Marcelia Hamada
3. 121611101080 Laura Willy Widiani
4. 131611101088 Emastari Rosyada Agustiana
Kelompok C2
No. NIM NAMA
1. 121611101050 Ghiza Jibrila Khumaira’ Barqly
2. 121611101077 Ayu Prativia Yonenda
3. 121611101083 Dewi Anggraini
4. 131611101034 Aditya Pristyhari
BAB 1. PRA KLINIK
BAB 2. KEGIATAN KLINIK PER KLINIK
2.1. Pencegahan dan Pengendalian Infeksi (PPI)

Tenaga pelayanan kesehatan gigi dan mulut di Indonesia mempunyai
kewajiban untuk selalu memenuhi salah satu kriteria standar pelayanankedokteran
gigi di Indonesia, yaitu melaksanakan Pencegahan dan Pengendalian Infeks (PPI).
Prosedur pelaksanaan tentang Pencegahan dan Pengendalian Infeksi tersebut harus
dilaksanakan pada semua fasilitas pelayanan kesehatan gigi dan mulut di seluruh
Indonesia. Dokter gigi harus dapat memastikan seluruh tenaga pelayanan yang
bekerja di dalam lingkungannya mempunyai pengetahuan dan mendapatkan
pelatihan yang adekuat tentang Pencegahan dan Pengendalian Infeksi. Hal tersebut
termasuk kebersihan tangan, pembersihan, disinfeksi dan sterilisasi peralatan serta
bahan yang digunakan. Teknik pembersihan, disinfeksi dan sterilisasi harus sesuai
dengan perkembangan keilmuan dan secara rutin dilakukan monitoring.
Infeksi merupakan bahaya yang sangat nyata pada praktik pelayanan
kedokteran gigi. Pada kenyataannya, prosedur kebersihan tanganmerupakan
komponen paling penting diantara program pencegahan dan pengendalian infeksi.
Tujuan Pencegahan dan Pengendalian Infeksi pada fasilitas pelayanan kesehatan
gigi dan mulut adalah untuk mencegah penularan infeksi baik kepada pekerja
layanan kesehatan maupun pasien ketika sedang dilakukan perawatan kesehatan
gigi dan mulut.
Central Sterilization Supply Department (CSSD) merupakan salah satu

mata rantai yang penting untuk pengendalian infeks dan berperan dalam upaya
menekan kejadian infeksi. Untuk melaksanakan tugas dan fungsi sterilisasi, CSSD
sangat bergantung pada unit penunjang medik maupun instalasi antara lain
perlengkapan, rumah tangga, pemeliharaam sarana rumah sakit, sanitasi, dan lain-
lain. Apabila terjadi hambatan pada salah satu sub unit di atas maka pada akhirnya
akan mengganggu proses hasil sterilisasi.
Target WHO 2020 salah satunya adalah meningkatkan jumlah pelayanan
kesehatan yang kompeten untuk mengenali dan mengurangi risiko dari transmisi
penyakit menular di lingkungan pelayanan kesehatan gigi dan mulut.
2.1.1. Defenisi CSSD

Sterilisasi adalah suatu proses pengelolaan alat atau bahan yang bertujuan
untuk menghancurkan semua bentuk kehidupan mikroba termasuk endospora dan
dapat dilakukan dengan proses kimia atau fisika. Sterilisasi sangat penting
dilakukan terutama untuk alat-alat bedah, terlebih lagi saat ini semakin
berkembangnya prosedur operasi maupun kompleksitas peralatan medik, maka
diperlukan proses sterilisasi yang tersentralisasi sehingga keseluruhan proses
menjadi lebih efesien,ekonomis dan keamanan pasien semakin terjamin. Disamping
itu, rumah sakit sebagai institusi penyedia pelayanan kesehatan berupaya untuk
mencegah terjadinya resiko infeksi bagi pasien dan petugas rumah sakit. Salah satu
indikator keberhasilan dalam pelayanan rumah sakit adalah rendahnya angka
infeksi nosokomial di rumah sakit. Untuk mencapai keberhasilan tersebut, maka
perlu dilakukan pengendalian infeksi di rumah sakit.
Istilah untuk pusat sterilisasi bervariasi, mulai dari Central Sterile Supply
Department (CSSD), Central Service (CS), Central Supply (CS), Central
Processing Department (CPD) dan lain lain, namun kesemuanya mempunyai
fungsi utama yang sama yaitu menyiapkan alat-alat steril dan bersih untuk
keperluan perawatan pasien. Secara terperinci, fungsi dari pusat sterilisasi adalah
menerima, memproses, memproduksi, mensterilkan, menyimpan serta
mendistribusikan peralatan medis ke berbagai ruangan di rumah sakit untuk
kepentingan perawatan pasien. Central Sterilization Supply Department (CSSD)
atau Instalasi Pusat Pelayanan Sterilisasi merupakan satu unit/departemen dari
rumah sakit yang menyelenggarakan proses pencucian, pengemasan, sterilisasi
terhadap semua alat atau bahan yang dibutuhkan dalam kondisi steril. Instalasi
CSSD ini merupakan pusat pelayanan yang bertujuan untuk memenuhi kebutuhan
alat/bahan steril bagi unit-unit yang membutuhkan sehingga dapat mencegah dan
mengurangi infeksi yang berasal dari rumah sakit itu sendiri. Alur aktivitas
fungsional CSSD dimulai dari pembilasan, pembersihan/dekontaminasi,
pengeringan, inspeksi dan pengemasan, memberi label, sterilisasi, sampai proses
distribusi. Berdirinya CSSD di rumah sakit dilatarbelakangi oleh:
1. Besarnya angka kematian akibat infeksi nosokomial
2. Mikroorganisme mudah menyebar, mengkontaminasi benda dan menginfeksi
manusia di lingkungan rumah sakit.
3. Merupakan salah satu pendukung jaminan mutu pelayanan rumah sakit, maka
peran dan fungsi CSSD sangat penting.
2.1.2. Struktur Organisasi Instalasi Pusat Sterilisasi

Instalasi pusat sterilisasi dipimpin oleh seorang Kepala Instalasi (dalam
jabatan fungsional) dan bertanggung jawab langsung kepada Wakil Direktur
Penunjang Medik. Untuk rumah sakit swasta, struktur organisasi dapat mengacu
pada struktur organisasi pemerintah. Hal-hal yang perlu dilaksanakan agar instalasi
pusat sterilisai dapat berjalan sebagai mana mestinya adalah perlunya pembagian
pekerjaan dalam jabatan fungsional. Struktur organisai pusat sterilisasi dapat dilihat
pada gambar 2.1. Struktur tersebut merupakan struktur minimal yang dapat diubah
sesuai dengan kebutuhan dan beban kerja pada masing-masing rumah sakit.
Gambar 2.1 Skema struktur organisasi instalasi pusat sterilisasi secara umum
2.1.3. Tugas Instalasi Pusat Sterilisasi

Adapun tugas CSSD di rumah sakit adalah :
1. Menyiapkan peralatan medis untuk perawatan pasien
2. Melakukan proses sterilisasi alat/bahan.
3. Mendistribusikan alat-alat yang dibutuhkan oleh ruangan perawatan, kamar
operasi maupun ruangan lainnya.
4. Memilih peralatan dan bahan yang aman dan efektif serta bermutu.
5. Mempertahankan stok inventory yang memadai untuk keperluan perawatan.
6. Mempertahankan standar yang ditetapkan.
7. Mendokumentasikan setiap aktivitas pembersihan, desinfeksi, maupun
sterilisasi sebagai bagian dari program upaya pengendalian mutu.
8. Melakukan penelitian terhadap hasil sterilisasi dalam rangka pencegahan dan
pengendalian infeksi bersama dengan panitia pengendalian infeksi nosokomial.
9. Memberikan penyuluhan tentang hal-hal yang berkaitan dengan masalah
sterilisasi.
10. Menyelenggarakan pendidikan dan pengembangan staf instalasi CSSD baik
yang bersifat intern dan ekstern.
11. Mengevaluasi hasil sterilisasi.
2.1.4. Sarana Fisik dan Peralatan

Sarana fisik dan peralatan di pusat sterilisasi sangat mempengaruhi efisiensi
kerja dan pelayanan di pusat sterilisasi rumah sakit. Dalam merencanakan sarana
fisik, dan peralatannya, sebaiknya melibatkan staf pusat sterilisasi. Mengingat pusat
sterilisasi merupakan jantung rumah sakit dimana tugas pokok pusat sterilisasi
adalah menerima bahan dan alat medik dari semua unit di rumah sakit untuk
kemudian diproses menjadi alat/bahan mediak dalam kondisi steril dan selanjutnya
mendistribusikan kepada unit lain yang membutuhkan kondisi steril, maka dalam
menentukan lokasi pusat sterilisasi perlu diperhatikan.
2.1.5. Bangunan dan Lokasi Instalasi Pusat Sterilisasi

Pembangunan Instalasi pusat sterilisasi harus sesuai dengan kebutuhan
bangunan pada saat ini serta kemungkinan perluasan sarana pelayanan
dimasadatang dan didesain menurut tipe atau kapasitas Rumah sakit dengan
ketentuan untuk Rumah Sakit :
1. 200 TT, luas bangunan kurang lebih 130 m2
Lokasi CSSD sebaiknya berdekatan dengan ruangan pemakai alat/bahan
steril terbesar di rumah sakit. Penetapan lokasi yang tepat berdampak pada efisiensi
kerja dan meningkatkan pengendalian infeksi yaitu dengan meminimumkan resiko
terjadinya kontaminasi silang serta mengurangi lalu lintas transportasi alat steril.
Untuk Rumah sakit yang berukuran kecil, lokasi pusat sterilisasi sebaiknya berada
dekat / diwilayah kamar operasi sesuai fungsinya dan diupayakan lokasinya dekat
dengan Laundry.
2.1.6. Ruangan Instalasi Pusat Sterilisasi

Pada prinsipnya, desain ruang pusat sterilisasi terdiri dari ruang bersih dan
ruang kotor yang dibuat sedemikian rupa untuk menghindari terjadinya kontaminasi
silang dari ruang kotor ke ruang bersih. Selain itu, pembagian ruangan disesuaikan
dengan alur kerja. Ruang pusat sterilisasi dibagi atas 5 ruang yaitu :
1. Ruang dekontaminasi
Pada ruang ini, terjadi proses penerimaan barang kotor, dekontaminasi dan
pembersihan. Ruang dekontaminasi harus direncanakan, dipelihara dan dikontrol
untuk mendukung efisiensi proses dekontaminasi dan untuk melindungi pekerja
dari benda-benda yang dapat menyebabkan infeksi, racun dan hal-hal berbahaya
lainnya. Syarat-syarat ruang dekontaminasi antara lain :
a. Ventilasi
- Sirkulasi udara yang dilengkapi dengan filter
- Pergantian udara 10 kali/jam
- Tekanan udara negatif
- Tidak dianjurkan menggunakan kipas angin
b. Suhu dan kelembaban
- Suhu 18-22°C
- Kelembaban antara 35-75%
2. Ruang pengemasan alat
Ruang pengemasan alat merupakan tempat pengemasan alat, bongkar
pasang alat, dan penyimpanan barang bersih.
3. Ruang Proccessing linen
Di ruang ini dilakukan pemeriksaan, pelipatan dan pengemasan linen yang
akan disterilisasi. Di ruang ini juga terdapat tempat tertutup untuk menyimpan
barang. Selain itu di ruangan ini juga dilakukan persiapan untuk bahan seperti kasa,
kapas, dan cotton swab.
4. Ruang sterilisasi
Di ruang ini dilakukan proses sterilisasi alat atau bahan. Untuk sterilisasi
etilen oksida, sebaiknya dibuatkan ruang tersendiri dan dilengkapi dengan saluran
pembuangan (exhaust).
5. Ruang penyimpanan barang steril
Syarat-syarat ruang penyimpanan barang steril antara lain :
a) Dekat dengan ruang sterilisasi
b) Suhu 18-22°C
c) Kelembaban 35-75%
d) Ventilasi menggunakan tekanan positif
e) Efisiensi partikulat 90-95% (untuk partikel berukuran 0, 5 μm)
f) Jauh dari lalu lintas utama
g) Dinding terbuat dari bahan yang kuat, halus dan mudah dibersihkan.
2.1.7. Aktivitas Fungsional CSSD

1. Pembilasan : Pembilasan alat-alat yang telah digunakan tidak dilakukan
diruang perawatan.
2. Pembersihan : Semua peralatan pakai ulang harus dibersihkan secara baik
sebelum dilakukan proses disinfeksi dan sterilisasi.
3. Pengeringan : Dilakukan sampai kering.
4. Inspeksi dan pengemasan : Setiap alat bongkar pasang harus diperiksa
kelengkapannya, sementara untuk bahan linen harus diperhatikan densitas
maksimumnya.
5. Memberi Label : Setiap kemasan harus mempunyai label yang menjelaskan
isi dari kemasan, cara sterilisasi, tanggal sterilisasi, dan kadaluarsa proses
sterilisasi.
6. Pembuatan: membuat dan mempersiapkan kapas serta kasa balut yang
kemudian akan disterilkan.
7. Sterilisasi : Sebaiknya diberikan kepada staf yang terlatih.
8. Penyimpanan : Harus diatur secara baik dengan memperhatikan kondisi
penyimpanan yang baik.
9. Distribusi : Dapat dilakukan berbagai sistem distribusi sesuai dengan
Rumah Sakit masing-masing.
2.1.8. Sistem Sterilisasi

Terdapat bermacam-macam metode sterilisasi, yaitu :
1. Sterilisasi panas kering
Digunakan untuk bahan yang bersifat termostabil, contoh : alat gelas,
sediaan farmasi. Untuk instrumen yang terbuat dari logam tidak dianjurkan untuk
distrerilisasi dengan cara ini. Waktu sterilisasi yang umum 160°C selama 60-150
menit dan 170°C selama 20-30 menit
2. Sterilisasi dengan panas uap
Jenis sterilisasi ini paling banyak digunakan di rumah sakit karena :
 Mudah pelaksanaannya
 Diterapkan hampir 80% kebutuhan (instrumen bedah, linen, dll)
 Biaya operasional rendah
 Hasil sterilisasi kering
 Waktu proses relatif pendek
Temperatur yang diperlukan pada sterilisasi jenis ini :
- 130°C selama 2 menit
3. Sterilisasi dengan ultraviolet
Karena terdapat keterbatasan daya tembusnya, maka sterilisasi ini
digunakan untuk :
- Sterilisasi udara (air hygiene)
- Inaktivasi mikroorganisme pada permukaan bahan atau tersuspensi dalam
cairan
- Untuk produk dalam komposisi yang tidak stabil yang sulit disterilisasi
dengan cara konvensional
Efek maksimum radiasi pada gelombang 265 nm. Sterilisasi dengan
ultraviolet masih dipakai dirumah sakit untuk tujuan mengurangi kontaminasi dan
dikontaminasi udara, contohnya pada ruang operasi
4. Sterilisasi dengan sinar pengion
Jenis sinar pengion yang digunakan adalah sinar gama dan sinar beta.
Digunakan untuk sterilisasi pada temperatur kamar. Kelemahan sterilisasi ini
adalah mahalnya biaya yang harus dikeluarkan untuk proteksi petugas yang bekerja
pada lingkungan sinar pengion. Sterilisasi ini digunakan untuk sterilisasi alat-alat
medis seperti : syringe, benang bedah, serta bahan-bahan yang terbuat dari plastik
dan karet.
5. Sterilisasi dengan gas kimia
Jenis gas yang digunakan adalah etilen oksid dan formaldehid. Keuntungan
sterilisasi ini antara lain :
- Digunakan untuk sterilisasi bahan yang bersifat termolabil (sterilisasi pada
temperatur rendah)
- Kemampuan penetrasi dan absorbsi etilen oksid yang tinggi pada beberapa
jenis pembungkus (kertas, polietilen)
- Digunakan untuk sterilisasi cateter, peralatan suntik plastik, dan sarung
tangan.
6. Serilisasi dengan filtrasi
Digunakan untuk mensterilkan udara atau bahan dalam bentuk cairan.
Contohnya adalah filter udara seperti HEPA (High Efficiency Particulated Air)
pada ruang operasi atau ruang isolasi tertentu untuk menghindari terjadinya
kontaminasi atau infeksi silang.
7. Sterilisasi dengan bahan kimia
Menggunakan jenis desinfektan tertentu yang bersifat high level
desinfectant seperti penggunaan glutaraldehid 2% untuk sterilisasi endoskopik.
2.1.9. Indikator Sterilisasi

Beberapa indikator sebagai salah satu kontrol kualitas dari proses sterilisasi
yang dilakukan yang meliputi :
1. Indikator Fisik
Indikator Fisik merupakan bagian dari instrumen mesin sterilisasi, yang
berupa lampu indikator suhu maupun tekanan yang menunjukkan apakah alat
sterilisasi telah bekerja dengan baik. Pengukuran temperatur dan tekanan
merupakan fungsi penting dari sistem monitoring sterilisasi, bila indicator mekanik
berfungsi dengan baik, maka setelah proses sterilisasi akan memberikan informasi
dengan segera mengenai temperatur, tekanan, waktu serta fungsi mekanik lainnya.
Indikator fisik tidak menunjukkan bahwa keadaan steril sudah tercapai, melainkan
hanya memberikan informasi dengan cepat tentang fungsi dari alat sterilisasi.
2. Indikator kimia
Indikator kimia adalah indikator yang menandai terjadinya paparan
sterilisasi pada objek yang disterilkan dengan adanya perubahan warna. Indikator
kimia yang digunakan berupa tape yang disebut dengan autoclave tape yang sensitif
terhadap satu atau lebih parameter sterilisasi. Indikator kimia belum dapat
menjamin tercapainya keadaan steril tetapi hanya menunjukkan bahwa suatu benda
sudah melewati kondisi-kondisi sterilisasi pada suatu siklus sterilisasi.
3. Indikator Biologi
Indikator Biologi ini berupa sediaan yang berisi populasi mikroorganisme
dalam bentuk spora hidup dan disertai media pertumbuhan yang sesuai. Ada yang
dimasukan dalam autoklaf dan ada yang diluar, untuk kontrol positif. Bila spora
indikator yang di dalam autoklaf tidak tumbuh setelah diaktifkan maka diasumsikan
semua kemasan dalam kondisi steril. Mikroorganisme yang
digunakan untuk indikator ini yaitu, Bacillus stearothermophyllus (sterilisasi uap)
dan Bacillus subtillis (sterilisasi etilen okside dan sterilisasi panas kering).
2.2. Poli Bedah RSD Balung

2.2.1. Standar Pelayanan Minimal (SPM) Bedah:
1. Kontrol infeksi di ruang bedah
Sebagai tindakan control infeksi di poli bedah Rumah Sakit Daerah
Balung, setiap pagi sebelum memulai pelayanan alat disterilkan ke dalam
autoclave yang tersedia di dalam poli Rumah Sakit Daerah Balung. Operator
harus menggunakan hands rub sebelum dan sesudah melakukan tindakan pada
pasien.
2. Tata laksana tindakan bedah
A. Kasus yang ditemukan di poli bedah:
1. a. Pasien laki-laki datang dengan keluhan luka pada sela-sela jari
kelingking kaki kanan.
b. Sebagai mahasiswa koas FKG yang dapat kami lakukan adalah
menulis kartu status, anamnesa pada pasien, mengukur tanda-tanda vital
pasien, observasi saat dokter jaga yang bersangkutan melakukan
diagnosis dan perawatan, menulis resep. Pada pasien ini, dokter jaga poli
bedah merujuk pasien untuk melakukan tes darah di laboratorium untuk
mengetahui penyakit yang menyertai dikarenakan saat anamnesa pasien
diketahui luka awal hanya berupa kutu air tetapi semakin lama luka
semakin melebar dan dalam, dicurigai pasien memiliki Diabetes
Mellitus.
2. a. Pasien perempuan datang dengan diagnosa tetanus. Pasien datang
untuk kontrol kondisi penyakit. Kondisi pasien saat datang
menggunakan kursi roda, luka sudah tertutup pada lengan tangan
sebelah kiri. Kondisi umum pasien lemas, sesak napas (terdengar suara
ronchi saat dilakukan pemeriksaan menggunakan stetoskop, pasien juga
mengalami degenerasi tubuh karena jarang digunakan untuk melakukan
aktivitas dan pasien kurang bersosialisasi.
b. Sebagai mahasiswa koas FKG yang dapat kami lakukan adalah
diagnosis dan perawatan, menulis resep. Setelah dilakukan pemeriksaan
tanda-tanda vital diketahui tekanan darah pasien tinggi sehingga dokter
jaga poli bedah merujuk ke poli penyakit dalam RSD Balung.
3. a. Pasien perempuan datang dengan keluhan terdapat benjolan kecil-
kecil (diameter kurang lebih 1 cm). Saat datang, pasien mengeluhkan
rasa sakit pada kakinya saat digunakan untuk berjalan. Sebelumnya,
pasien sudah diberi obat untuk meringankan rasa sakit yang dialaminya,
tetapi benjolan pada kaki tidak membaik. Pasien diinstruksikan untuk
menjadwalkan tindakan operasi untuk menyembuhkan penyakitnya ini.
Namun, sebelum itu, pasien dirujuk ke laboratorium terlebih dahulu
untuk melakukan tes darah.
b. Sebagai mahasiswa koas FKG, hal yang dapat kami lakukan adalah
diagnosis dan perawatan, dan menulis resep.
4. a. Pasien laki-laki datang untuk kontrol luka pasca operasi hernia di
area kelamin.
pasien, dan menulis resep.
5. a. Pasien laki-laki datang mengeluhkan terdapat benjolan di belakang
telinganya sejak 6 bulan yang lalu. Saat berada di GMC tiga bulan
sebelumnya, benjolan tersebut sempat dipecahkan oleh tenaga
medisnya, namun tumbuh lagi benjolan di tempat yang sama. Setelah
itu, dipecahkan lagi di GMC sekitar tiga minggu yang lalu, namun
benjolan tersebut tumbuh lagi di tempat yang sama. Benjolan tersebut
terdapat pada telinga sebelah kiri dengan diameter kurang lebih 1 cm
dan berisi nanah. Pasien diinstruksikan untuk menjadwalkan tindakan
operasi untuk mengangkat benjolan tersebut. Namun, sebelum itu,
pasien dirujuk terlebih dahulu ke laboratorium untuk melakukan tes
darah.
diagnosis dan perawatan, dan menulis resep.
6. a. Pasien laki-laki datang ingin kontrol luka pasca operasi di
pergelangantangan kiri akibat teriris pisau. Kondisi luka dan keadaan
jahitan baik, keadaan umum pasien juga baik.
diagnosis
dan perawatan, dan menulis resep.
B. Visite
Pada pagi hari sebelum poli bedah membuka pelayanan, kami
melakukan visite di ruang rawat inap bedah Mawar. Saat visite, kami
melakukan observasi pada beberapa pasien post tindakan operasi, seperti
pasien wanita dengan diagnosa hemorrhoid, pasien laki-laki dengan kanker
anus yang memerlukan selang untuk pembuangan kotoran dari bagian
abdomen, pasien dengan batu pada saluran kencing, dan pasien post operasi
luka infeksi di jari kaki sebelah kanan.
2.3. Poli Penyakit Dalam RSD Balung

Kegiatan di poli penyakit dalam di bimbing oleh dr.H.A.
Yudho.,Akp.,Sp.PD.,FINASIM. Di Poli Penyakit Dalam komunikasi yang
dilakukan antara mahasiswa coass Kedokteran Gigi dan dr.Yudho selaku dokter
pembimbing menggunakan bahasa inggris. Masing - masing kelompok berada di
Poli Penyakit Dalam selama 2 hari.
 Hari ke 1
Pada hari pertama, kami melakukan anamnesa terhadap pasien yang datang ke Poli
Penyakit Dalam. Kami sebagai mahasiswa coass Kedokeran Gigi melakukan
pemeriksaan subjektif dan objektif pada rongga mulut pasien untuk melihat
manifestasi penyakit sistemik dalam rongga mulut. Setelah itu, hasil dari anamnesa
kasus didiskusikan dengan dokter pembimbing. Setelah diskusi selesai, dokter
pembimbing memberikan tugas untuk dikerjakan dirumah.
 Hari ke 2
Pada hari kedua, kami bersama dokter pembimbing mengunjungi ruang VCT
(Voluntary Counseling and Testing) pasien HIV/AIDS dan Tuberculosis dan ruang
rawat inap melati untuk visite pasien dari Poli Penyakit Dalam. Di ruang VCT kami
melakukan anamnesa pada pasien seperti hari pertama. Kemudian, hasil anamnesa
kasus kami diskusikan dengan dokter pembimbing. Setelah diskusi selesai, dokter
pembimbing memberikan tugas untuk dikerjakan dirumah.
2.3.1. Hasil Diskusi Kasus dan Tugas
2.3.1.1.Gastritis
a. Gastritis treatment before odontectomy:
1. Make sure gastritis is treatment well after that we can done the odontectomy.
2. If pain from gastritis exist we have to eliminate the pain from gastritis.
3. We have to choose the right medicine to control the pain after surgery.
NSAID medicine make the gastritis become worst. So we have to avoid
using NSAID analgesic in patient with gastritis.
b. Another method that cause dental caries in gastritis patients
The cause of dental caries in the oral cavity of gastritis patient through
stomach acid up into the oral cavity is true, therefore dental caries in the patient
only concern on the palatal side of molar teeth. But the rise of stomach acid
also causes other diseases besides caries, namely periodontal disease. This is
because bacteria H. phyloris, in some journals mention the discovery of H.
phyloris in the periodontal and gingival region. When there is a reflux of
bacteria that should be in the intestinal remains in the oral cavity so that it can
cause periodontal disease. This incident is also the cause of reinfection in
patient with gastritis sufferers.
2.3.1.2.Hypertention
a. Bleeding management in hypertension.
1. Blood pressure optimum before tooth extraction is <140/80 mmHg
2. Bleeding management after odontectomy due to increasing blood pressure
is using hemostatic agent (absorbable gelatin sponge) on socket then
hecting. If bleeding doesn't stop, be able to use intravenous or intramuscular
hemostatic agent (tranexamic acid)
b. How to do extraction on a patient with 200 mmHg blood pressure?
while the patient must do the procedure before extraction we can give drug with
short acting antihypertension treatment like captopril 25 mmHg or nifedipin. Then
check the blood after a hour if the patient have a normal blood pressure then we can
do the tooth extraction to the patient. control of pain and anxiety is very important
with high medical risk such as hypersensitive. The use of local anesthetic with
epinephrine produce a longer and more effective anesthetics than single LA, thus
avoiding an exaggerated response to stress. Local anesthetics with vasoconstrictor
should be avoided or used in low doses in patients taking nonselective beta-blockers
or in patient with uncontrolled hypertension.
c. Oral manifestation of hypertension

Indeed, hypertension does not directly manifest in the oral cavity. Anti-
hypertensive drugs that directly affect the oral cavity. These are some of the
manifestations of anti-hypertensive drugs in the oral cavity:
1. Gingival bleeding was clinical features seen in hypertensive patients.
2. Hypo salivation was also found as one of the clinical manifestations in
hypertensive patients. This hypo salivation was related with increase in both
systolic as well as diastolic blood pressure and also in patients with
antihypertensive medication especially with diuretics.
3. Lichen planus like lesions or lichenoid reactions are white lesions
characterized by linear striations occurring on the buccal mucosa. They are
seen bilaterally and usually in the posterior regions. These are sometimes
seen in hypertensive patients as a manifestation secondary to the use of the
drug or medication (ACE inhibitor drugs).
4. Gingival enlargement is also clinical features in patients with hypertension
taking anti-hypertensive medication especially calcium channel blockers.
d. Based in blood pressure 161/84 what stage is that hypertension?
JNC 8 (Joint National Committee (on prevention detection evaluation and treatment
of high blood pressure). Blood pressure is classified into one of four categories:
normal, prehypertension, stage 1 HTN (hypertension) and stage 2 HTN.
Prehypertension is not considered a disease, but identifies those who are likely to
progress to stage 1 or stage 2 HTN in the future. Normal: <120/<80 mmHg.
Prehypertension: 120-39/80-89 mmHg. Stage 1 HTN: 140-140/90-99 mmHg. Stage
2 HTN: ≥160/≥100 mmHg. So from the case, blood pressure 161/84 is classified as
stage 2 HTN.
2.3.1.3.Diabetes Melitus
a. How to do tooth extraction on a patient with 800 mg/dl blood glucose while
the patient only has 6 hours left to do the complete procedure.
Before tooth extraction, we can inject insulin analog (a fast working insulin) who
has the optimum effect in 1-2 hours. Then check the patient's blood glucose. If the
number of the blood glucose is normal, we can do the tooth extraction procedure.
But if the blood glucose number is not normal, its best that we delay the procedure
until the patient has a controlled number of blood glucose.
b. Management in Diabetes Mellitus related xerostomia
One of many oral manifestation in patient with diabetes mellitus is xerostomia,
xerostomia is feel of dryness in mouth due to lack of saliva and make patient feel
thirsty (polydipsia). Xerostomia can present in DM patient because of autonomic
neuropathy diabetic (glossopharyngeal nerve), Polyuria also can be lead into
xerostomia, poor glycemic control and poor hydration.
1. Management of xerostomia.
2. Control of blood sugar,
3. Hydration,
4. Consume fruit and vegetables or sugar free gums to stimulate saliva flow
5. using alcohol-free oral rinse, gels or mouthwash (no flavoring, better
contain Aloe vera, vitamin e to moist oral mucosa
6. sugar free gums to stimulate saliva flow,
7. Salivary substitute can be use in patient who have no residual salivary gland
function.
c. How is the pathophysiology steroid that can increase insulin resistance?
1. Steroid works by reducing the activity of the body's immune system and
reducing inflammation, so steroid can prevent the tissue damage
2. steroid can cause blood glucose level increase by making the liver resistant
to the insulin produced by the pancreas
3. Physiology: when the blood glucose level is high, insulin secreted from
pancreas and delivered to the liver. Then, insulin make signal to reduce the
amount of blood glucose. After that, glucose is transported from
bloodstream to cells. In the end blood glucose level is reduce.
4. Pathophysiology: steroid can make liver less sensitive to insulin. Steroid
makes the liver continue releasing sugar even if the pancreas signaling to
stop. If it is continue, it cause insulin resistance. Insulin resistance is happen
when the cells no longer respond to insulin to control blood glucose. And
then, diabetes is happen. This condition is called: steroid-induced diabetes
d. In diabetic patient, changes to the capillaries such as thickening of the basement
membrane result in altered permeability, impeded migration of leucocytes and
impaired hyperemia, tissue hypoxia. These changes can adversely affect the
outcome of surgery, resulting in poor wound healing and wound infection.
1. Firstly, avoid vigorous rinsing patient's mouth as it can dislodge the cloth
formed on the extraction site.
2. Place a piece gauze to block the bleeding 30 minutes. If the bleeding still
exist, change the gauze with a new one which is added adrenaline before.
Adrenaline is vasoconstrictor that help the tissue's wound healing to stop
bleeding, in case the patient with compromised diabetic had a poor wound
healing.
3. If the patient, bring his insulin injector, it may use to control the blood
glucose level just in time.
4. We need to do all the procedures safe from contamination, because patient
with compromised diabetic had a high risk of infection.
e. Oral manifestations of diabetes mellitus, most popular abnormality in the oral
cavity.
The most common oral health problems associated with diabetes can be listed as:
 Gingival/Periodontal disease
 Salivary gland dysfunction
 Fungal infections
 Dental caries
1. Gingival/Periodontal disease
Periodontal disease is a very well documented complication of diabetes, it
was found to be more common in insulin dependent diabetes mellitus
(IDDM) and in long standing diabetes. It was observed that attachment loss
was more in older patients, while bleeding on probing and calculus being
constant across the various age categories. In 45 years old patients with
family history and periodontitis, probabilities of occurrence ranged from 53-
27%, with age probabilities increased. Periodontal disease may begin as
gum disease with classic manifestations of doughy gingiva and abscesses
which if untreated may lead to gradual destruction of the tooth’s supporting
tissues and, ultimately, tooth loss in patients with poor resistance.
Fig 2.2. Periodontal disease with oedema on gums, tooth mobility, tooth loss,
calculus, caries and gingival recession
2. Salivary Gland dysfunction

Previously, it was mentioned that about 40-80% of diabetic patients report
of salivary dysfunction. Salivary dysfunction leads to dry mouth which may
favor the accumulation of plaque, dental caries, mucositis, periodontal
infections, malodor, ulcers, in amed depapillated tongue, impaired ability to
wear denture and inability to chew and swallow the food and taste
dysfunction. Diabetic patients with poorly controlled disease have been
found to have lower stimulated parotid flow rates than people with well-
controlled DM and nondiabetic control subjects.
3. Fungal Infections
Previously, it is also observed that the oral candidiasis was more prevalent
in IDDM with decreased salivary function than healthy control. In a study,
the commoner oral manifestations of oral candidiasis were median
rhomboid glossitis, diffuse atrophy of tongue papillae, denture stomatitis
and angular cheilitis. Apart from candida albicans that is commonly seen,
Candida dubliniensis could also be isolated from few patients of diabetes
mellitus. The other fungal infections such as mucormycosis and
zycomycosis may occur in diabetics especially when uncontrolled and may
manifests as palatal ulcerations or necrosis.
Fig 2.3. Oral candidiasis on tongue
4. Dental Caries
Diabetic patients have more active dental caries than control subjects.
Increased levels of glucose in saliva and gingival crevicular fluid may
increase susceptibility towards dental caries. The diminished salivary flow
is may be an additional risk factor for dental caries. Oral manifestations in
patient DM that we visited today are ulcers in mouth, periodontal disease
(edema in gums, tooth mobility, Tooth loss, and gingival recession), dental
caries, dental calculus, halitosis and oral candidiasis.
f. What the relationship between Diabetes mellitus and oral candidiasis?
Fungal infections are more common in diabetes mellitus, particularly those caused
by candida. The distinction between infection and colonization can be difficult. The
presence of urinary symptoms or pyuria suggests infection. Fungal may result in
the formation of fungal balls. Which may complicate as urinary tract obstruction.
Pseudomembran candidiasis is also known as oral thrush. It is characterized by the
presence of creamy white patch which, when wiped, reveals underlying
erythematous and bleeding oral mucosa. Fungal infection in patient with diabetes
mellitus has been recognized for many years. Candidal infection is reported to be
more prevalent in patients who have poor glycemic control and use broad spectrum
antibiotics.
2.3.1.4.Dyspepsia
a. What suggest to patient with dyspepsia to keep their oral hygiene?
First of all, patient with dyspepsia vomited many times which can change the pH
of oral cavity that can lead to caries. Thus, we can keep pH of oral cavity with
following steps:
1. Avoidance of tooth brushing after vomiting or acid exposure of the teeth
2. Using toothpaste, preferably a low abrasive formula and contain fluoride
3. Include modification to reduce extrinsic source of acid, such as reduction of
dietary acid and careful rinsing of the mouth after vomiting or acid exposure
4. Use of neutralizing agent such as sugar free antacid held in mouth after
vomiting or acid exposure
5. Salivary flow simulation by use nonacidic sugarless candies
b. Dyspepsia according to ROME III and Oral manifestation of Dyspepsia.
1. Dyspepsia comes from Greek word "dys" and "peptein" which roughly
translated to "Bad Digestion". Dyspepsia is a syndrome with symptoms of
stomach fullness and heartburn during the last 3 months, with onset at least
6 months before diagnosis. It can be divided into organic and functional
type; functional dyspepsia is further classified to postprandial distress
syndrome and epigastric pain syndrome according to Rome Criteria III
2. Oral manifestations:
Enamel erosion was found in the patient. It is the most common dental
manifestation of dyspepsia because of the demineralization action by the
acid reflux. Dental enamel consists primarily of a calcium phosphate
mineral in the form of carbonated hydroxyapatite (CHA). CHA is insoluble
in an alkaline medium. However, its solubility increases with a decrease in
the oral pH. This effect was first noted as a result of direct contact of the
tooth surface with acids from extrinsic sources such as beverages. Unlike
dental caries, where the demineralization is caused by an acidic environment
produced by plaque bacteria, the acidic environment in dyspepsia is due to
the reflux of hydrochloric acid from stomach. The erosive effect tends to be
localized on the palatal aspects of the maxillary teeth. The progressive steps
of erosion that was found in patient are as follows:
a) Chalky or "frosted" appearance
b) Smooth, glazed appearance
c) Eroded and thinned enamel
d) Cupping of cusp edges of posterior teeth
e) Flat occlusal surfaces
3. The other manifestations that can be found in patient are:
a) Dry mouth
b) Burning sensation
c) Halitosis
d) Erythema of the palatal mucosa and uvula
These manifestations caused by the reflux of hydrochloric acid from
the stomach into the esophagus. Thus the esophagus becomes irritated or
inflamed which induce the burning sensation and the other manifestations.
c. Why dental calculus become oral manifestation in patient with dyspepsia?
Some oral manifestations in patients with dyspepsia are dental caries, dissolution
of the tooth enamel, dry mouth, feeling at oral acid or burning sensation, halitosis,
erythema of the palatal mucosa and uvula. Oral manifest also influenced by other
causes like dietary factors, drugs, poor oral hygiene, eating behavior disorders, and
genetic. In patient Sumainah (67 years old) was found calculus, oral candidiasis,
caries, and tooth attrition. The calculus that was found may causes by poor oral
hygiene and xerostomia because side effect of drugs. This patient using partial
denture in maxilla from non dentist (tukang gigi) so the denture can’t be removed.
this cause the denture can’t clean periodically so debris and food accumulate in the
denture that make oral colonization that make dental plaque. Several investigations
have shown that after the insertion of partial dentures, the mobility of the abutment
teeth, gingival inflammation, and periodontal pocket formation all increase. This is
because partial dentures favor the accumulation of plaque, particularly if they cover
the gingival tissue. Partial dentures that are worn during both night and day induce
more plaque formation than those worn only during the daytime. The presence of
removable partial dentures induces not only quantitative changes in dental plaque
but also qualitative changes, promoting the emergence of spirochetal
microorganisms. Medications taken by patients for the treatment of dyspepsia
disease can produce oral manifestations. PPIs (proton pump inhibitor) can alter taste
perception. Cimetidine and ranitidine may have a toxic effect on bone marrow,
infrequently, they cause anemia, agranulocytosis, or thrombocytopenia. Mucosal
ulcerations may be a sign of agranulocytosis, whereas anemia may manifest as
mucosal pallor, and thrombocytopenia as gingival bleeding or petechiae.
Xerostomia has been associated with the use of famotidine and anticholinergic
drugs, such as propantheline (Pro-Banthine). A chronic dry mouth renders the
patient susceptible to bacterial infection (caries and periodontal disease) and fungal
disease (candidiasis). Erythema multiforme has been associated with the use of
cimetidine, ranitidine, omeprazole, and lansoprazole. Xerostomia can increase the
plaque accumulation, increased incidence of tooth decay, enamel demineralization,
enamel attrition and erosion, etc. Beside that H. pylori that usually associated with
dyspepsia is found in dental plaque and may serve as a reservoir of infection and
reinfection along the alimentary tract. Good oral hygiene measures and periodic
scaling and prophylaxis may be useful in reducing the spread of this organism. The
need for rigorous hygiene measures should be explained to the patient, and consid-
eration given to laboratory detection of oral organisms in patients who have a
history of dyspepsia disease and are symptomatic or are experiencing recurrences.
Routine dental care requires no other modifications in technique for patients with
dyspepsia disease.
2.3.1.5.COPD
a. How to do tooth extraction on a patient with COPD.
Before tooth extraction, its best that we delay the procedure until the patient has
a controlled breathing. Patients COPD may require oxygen and oximetry
monitoring during the appointment, and specialized clinics are able to offer oxygen
equipment and personnel trained in its use. Some patients require dental chair
adjustments, because breathing is compromised in the supine position. Semi-supine
or upright chair positions are usually best tolerated. Short appointments should be
planned to decrease stress if the patient does not tolerate prolonged sitting in a
dental chair. Rubber dam use should be modified in some cases ‒ and avoided if
possible ‒ because this may further obstruct breathing, and patients may complain
of a suffocating sensation. Patient with obstructive pulmonary disease are best
managed with local anesthesia for our patient procedures. The selection of local
anesthetic is important when treating COPD. Many local anesthetic solutions
contain sulfites which precipitate acute asthmatic attacks and allergic reactions.
These compounds are found in local anesthetic preparations containing epinephrine
and levonordefin and the preparations should not be used. If the patient is treated
with local anesthesia the bronchodilator inhaler should be kept ready for use in case
of emergency. If there is an acute attack on the table patients can use nebulizer with
bronchodilator like salbutamol.
2.3.1.6.Tuberculosis
a. What kind of masker we should wear to prevent TB transmission?
Masker N95. This masker protect us from microorganisms *including TB and some
small particles. Consist of 4 layer with nose foam.
b. Human immune system in TB :
Immune responses to Mycobacterium tuberculosis are only partially effective after
the bacteria entering our body, the bacteria will spread to alveoli through the
respiratory tract, then make colonies. This also can spread through the lymphatic
system and blood flow to other organs (renal, bone). Early infection usually occurs
in 2-10weeks after exposed by bacteria. The first interaction between bacteria and
immune system make a new mass tissue called granuloma (consist of dead and live
bacteria colonies surrounded by macrophage, looks like wall). Then, it turns into
fibrotic tissues. The material that consists of necrotic macrophage and bacteria then
become "necrotizing caseosa". It will turn into collagen tissues, and the bacteria
become inactive. The system drive the bacteria into a latent state, but rarely
eliminate them. Unfortunately, the latent state of M. tuberculosis is reversible, and
reactivation tuberculosis is the source of most transmission.
c. Health care particular respiratory for medical service N95 or FFP is a special
mask contain high efficiency for defends people from less than 5 micron
particle that brought by the air. This mask contain several filters and it must be
used properly without any leak. This mask makes users respiratory more
difficult. The price is higher than surgical mask.
d. The name of tuberculosis at oral cavity is "Oral Tuberculosis". Oral
manifestation of TB are uncommon and the presentation is nonspecific that
cause difficulties in diagnosis. Ulcer is the most common manifestation of oral
TB, Both of primary and secondary TB. The secondary TB is observed more
often than the primary. In primary TB, the characteristic is a non-painful ulcer
is accompanied by the local lymph nodes enlargement. In secondary TB, There
is painful ulcer. Painful changes may interfere with speech and food ingestion,
and often cause hyper salivation. The lymph nodes may be non-palpable or
enlarged, with a tendency to their softening in the advanced stage of the
disease.
e. Needle stick injury is subcutaneous injury caused by needle stick or contact at
mucosa membrane. Treatment for NSI:
1. Don’t be panic
2. Get off the blood soon by massaging the injury and wash it with flowy
water using soap and antiseptic
3. Tell the K3RS Team and continued the information to PPI team.
4. Assessed patient as a source of HIV, HBV, HCV
5. The medical crew who have beed sticked by needle will be examined
his/her HIV, HBV, HCV status
6. If the patient free from the HIV, HBV, HCV or not in incubation time, so
it’s no need special treatment for the medical crew
7. If the patient status is positive HIV, HBV or HCV therefore we have to
assessed the status of medical crew that have been sticked
f. What is the oral abnormality in patient with TB?
Oral TB lesions may be either primary or secondary lesions. Primary lesions are
uncommon, and present as single painless ulcer with regional lymph node
enlargement. The secondary lesions are common, often associated with usually
present as single, indurated, irregular, painful ulcer covered by inflammatory
exudates. Oral TB may occur at any location on the oral mucosa, include the palate,
lips, buccal mucosa, gingiva, palatine tonsil, and floor of the mouth but the tongue
is most commonly affected. The oral manifestations of TB can also be in form of
superficial ulcers, patches, and indurated soft tissue lesions. Of all these oral
lesions, the ulcerative form is the most common. But in patient TB that we visited
today there is no lesion in his oral mucosa and from this journal said that
tuberculosis oral lesions have a relatively rare occurrence. The incidence has been
reported as less than 0.5-1% amongst all the Tuberculosis patients, according to
various studies.
Fig 2.4 & 2.5. Multiple ulcers on the posterior left and right sides of buccal mucosa
Fig 2.6. Oral trush (pseudomembrane candidiasis). Presents as white yellowish formation
on tongue surface
Fig 2.7. Angular cheilitis on both side of lip corners
Fig 2.8. Periodontitis
2.3.1.7.Liver Disease
a. What is the impact NSAID usage routinely in dental clinic in the liver system?
Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely
prescribed analgesics for management of post-operative pain in dental patients.
But, Non-steroidal anti-inflammatory drugs (NSAIDs) which consumed
massively worldwide and, along with antimicrobial agents, are the most
frequent causes of drug-induced liver injury (DILI). Nonsteroidal anti-
inflammatory drugs (NSAIDs), including both the traditional nonselective
NSAIDs and the selective cyclooxygenase (COX)-2 inhibitors, are widely used
for their anti-inflammatory and analgesic effects. They are routinely prescribed
in dental practice for the management of pain and swelling. Their use in treating
acute dental pain and chronic orofacial pain, as adjuncts to the treatment of
periodontal disease, and to minimize edema following surgical procedures is
well documented. However, long-term utilization of nonselective NSAIDs
could increase the risk of gastrointestinal symptoms, ranging from mild (e.g.,
dyspepsia, nausea, or vomiting) to serious gastric problems (e.g., gastric
bleeding or perforation). Therefore, selective COX-2 inhibitors have been
developed with fewer GI side effects but the recently identified cardiovascular
adverse reactions limit their routine use in dental practice. Another major
concern for oral physicians is NSAID-induced mucosal lesions and
prolongation of bleeding time during invasive dental procedures. This article
reviews therapeutic and analgesic uses of NSAIDs in dentistry. The various
issues surrounding NSAID-induced adverse reactions and their implications in
dentistry are also discussed.
b. What is the oral manifestation of patient with liver disease?
Patient with liver disease that had visited this morning shown several oral
manifestation such as gingivitis (gingival bleeding), petechiaes on palatum
molle, tooth caries, oral candidiasis, xerostomia, halitosis. I also found jaundice
in patient's eyes even these didn’t appears in oral cavity. Liver has a broad range
of functions in maintaining homeostasis and health. In situation of liver disease,
the vitamin K levels become lower, thus giving rise to reduction in production
of blood coagulation factors. Resultant of impaired hemostasis can manifested
in the mouth as petechiaes and gingival bleeding with minor trauma. There were
studies have shown that there is an increased incidence of dry mouth in patient
with liver disease, especially those patients on antidepressants, in addition to
the known effect of virus (such as HCV) on salivary glands. Salivary depletion
may result in dental caries, burning sensation in the mouth, candidiasis and
halitosis. Jaundice/yellowish pigmentation on the conjunctiva of the eye due to
high bilirubin levels on the patient with liver. In the oral mucosa, the
discoloration is more frequently found at the junction between hard and soft
palate, ventral surface of the tongue and cheeks, due to the affinity of elastic
fibers for bilirubin.
2.3.1.8.HIV-AIDS
a. Mention the oral manifestation of HIV according to the HIV stages
1. Stage 1: the primary HIV infection phase  this is the stage is when a
person's HIV status change from HIV negative to HIV positive. The window
period is about 3-4 weeks and may be longer with others individual. At this
stage in oral cavity HIV develop flu like symptoms such as sore throat and
(occasionally) oral ulcers. This symptoms usually last from between one or
two weeks.
2. Stage 2: asymptomatic latent phase  in this stage the infected person
display no symptoms. Even though the person may ignorance of HIV
presence, the virus remains active in the body during this stage and it
continues to damage and undermine its victim’s immune system. In some
case the only symptoms on this phase is swollen glands
3. Stage 3: the minor symptomatic phase of HIV disease  in this stage minor
and early symptoms of HIV disease usually begin to manifest. At this stage
the viral load is high and the immune system is not coping and manifests
itself by the occurrence of opportunistic infections. This phase usually starts
when people with HIV antibodies begin to present with one or more of the
following symptoms in oral cavity like :
a) oral candidiasis (thrush)
b) Oral hairy leukoplakia
c) Shingles (herpes zoster)
d) Sore in the mouth that come and go
4. Stage 4: AIDS (Mayor UU symptomatic phase of HIV infection and
opportunistic disease)  the fourth stage is known as Aids. Major symptoms
and opportunistic diseases begin to appear as the immune system continues
to deteriorate. At this point, the CD4 cell count becomes very low while the
viral load becomes very high. The following symptoms in oral cavity are
usually an indication of advanced immune deficiency :
a) Oral thrush infections which are very persistent and recurrent (Candida)
b) Esophageal candida (thrush in the food pipe)
c) Recurrent herpes infections such as cold sores (herpes simplex)
d) Recurrent herpes zoster (or shingles)
e) Oral hairy leucoplakia (thickened white patches on the side of the tongue)
b. What kind of opportunistic infections on patient with HIV/AIDS that included
to the most common complication in HIV/AIDS?
Patients with human immunodeficiency virus (HIV) infection often develop
multiple complications and comorbidities. Opportunistic infections should
always be considered in the evaluation of symptomatic patients with advanced
HIV/AIDS. Opportunistic infections are the most common complication in
HIV/AIDS patient.
The most common infections are:
1. Neuropsychiatric : Primary central nervous system lymphoma, Chronic
psychiatric disorders
2. Head and neck : Gingivitis, dental and salivary gland disease, candidiasis
(oral thrush)
3. Cardiovascular : Cardiovascular disease, endocarditis
4. Pulmonary : Chronic obstructive pulmonary disease, lung cancer
(including Kaposi sarcoma and lymphoma), pneumonia, pneumonitis:
CMV, invasive fungi, Pneumocystis jiroveci (formerly Pneumocystis
carinii), T. Gondii, Pulmonary tuberculosis: Mycobacterium tuberculosis
5. Gastrointestinal: Viral hepatitis, lymphoma, Kaposi sarcoma, HPV-
related malignancies
6. Renal/genitourinary : Chronic kidney disease not caused by HIV-
associated nephropathy
7. Endocrine : Adrenal gland infiltration: CMV, invasive fungi,
Mycobacterium species
8. Musculoskeletal : Osteopenia, osteoporosis, osteonecrosis
9. Hematologic or oncologic : Lymphoma, multiple myeloma
10. Dermatologic : Papulosquamous disorders (e.g., eczema, seborrheic
dermatitis, psoriasis); molluscum contagiosum; Kaposi sarcoma
c. Definition of Lichen Planus and it appearance in each stages of HIV?
Oral Lichen Planus has been found to be associated with various viral agents
such as human papilloma virus (HPV), Epstein Barr virus (EBV),human herpes
virus 6 (HHV-6)and human immunodeficiency virus (HIV). Lichen Planus
may occur in immunocompromised hosts such as patients with abnormal
humoral immunity, occurring as an associated feature of HIV infection.
Oral Lichen Planus is characterized by lesions consisting of radiating white,
gray, velvety, thread-like papules in a linear, annular and retiform arrangement
forming typical lacy, reticular patches, rings and streaks. The lesions are
asymptomatic, bilaterally/symmetrically anywhere in the oral cavity, but most
common on buccal mucosa, tongue, lips, gingiva, floor of mouth, and palate.
There have been several studies examining the immunophenotype of the
lymphocytic infiltrate in LP, it was found that the infiltrate, which initially was
predominantly CD4-positive in early lesions, later changed to a CD8-positive
infiltrate in older lesions. This suggests that the age of the lesion may determine,
in part, whether the predominant T lymphocyte is helper or suppressor,
correlating further with the stages and progression of HIV. CD4 dominates the
lesion in early stage of HIV and CD8 in the later stage.
d. Pathogenesis xerostomia in HIV patient?
Xerostomia and reduced salivary flow have been associated with HIV when its
early stages of discovery. In HIV positive individual, the function of
submandibular and parotid gland are affected. When both of them have
function to produce saliva. The exact cause of xerostomia in HIV patients is
unknown. But from the side effects of antiretroviral drugs (ARVs), fatty
infiltration of the parotid gland maybe one of the causes, due to swelling of the
parotid gland that inhibits salivary flow.
2.3.1.9.Heart Disease
a. What should you do if there is patient with rheumatic heart disease wanna
extraction the tooth but the patient has strep throat or strep pharyngitis?
If the patient/client has suspected or laboratory-confirmed strep throat or is
otherwise unwell with oral manifestations and related signs and symptoms.
Refer to primary care provider (e.g. physician or nurse practitioner) for follow-
up and definitive diagnosis (e.g. throat swab and culture or rapid strep test).
Instruct patient/client to reschedule dental hygiene appointment when s/he feels
well AND when antibiotic therapy has been initiated for at least 24 hours if
strep throat has been diagnosed. If there is a patient/client history of rheumatic
fever (now rare in developed countries), it is most prudent to wait until the
course of antibiotic treatment has been completed. Antibiotic regimens such as
penicillin V and most alternatives-typically require a 10 day course to achieve
successful treatment and prevent post-streptococcal complications. A notable
exception is azithromycin which, given its long half-life, requires only 5 days
of therapy.
2.3.1.10. Thyroid Carcinoma

a. Oral manifestations of thyroid carcinoma
Thyroid carcinoma is the most common endocrine cancer which is also called
by thyroid cancer. Thyroid cancer is a malignant tumor/growth originating
within the thyroid gland. Oral findings in patient with thyroid carcinoma such
as:
1. Lips form. The lips were diffusely enlarged and appeared everted and
patulous. There were palpable masses in both the upper and lower lips. The
most prominent and unsightly mass was in the midline of the upper lip.
There were flattened, plate-like projections just adjacent to the labial
commissure, bilaterally. The lips conditions of the patient at melati room
which is diagnosed by thyroid carcinoma present this clinical feature.
2. The anterior one-third of the tongue presented with regularly shape, round,
raised lesions which is resembled the size of circumvallate papillae. This
clinical feature does not appear in patient at melati room, the patient's tongue
appeared to be long and narrow and having normal function movements.
3. There is multiple diastema between the permanent teeth and anterior
protrusion of maxillary and mandibular dental arches were present.
4. The gingival tissue was not hypertrophied, however it was inflamed and
tended to bleed easily. The patients at melati room has calculus and it cause
the gingival tissue easy to bleed so the oral hygiene was not really excellent.
5. Some of patient’s complaint of pain and swelling in the right are left lower
face for the last 1 month, which started after the mobile teeth in the same
region (right or left) exfoliated spontaneously. There was uncontrolled
bleeding from these sockets so we have to put an extremely attention to this
patients because it can be the thyroid carcinoma have been metastasized in
the mandible. But the metastases in the oral tissues are rare events. In the
oral cavity, the most common site is the body of mandible in the premolar
and molar region.
2.3.1.11. Dental Caries

The caries classification
1. According caries lesions we use GV. Black's classification of dental caries
Class 1: caries affecting pits and fissures on occlusal third of molars and
premolars, occlusal two-thirds of molars and premolars and lingual part of
anterior teeth.
Class 2: caries affecting proximal surfaces of molars and premolars.
Class 3: caries affecting proximal surfaces of central incisors, lateral incisors
and cusped without involving the incisal angles.
Class 4: caries affecting proximal including incisal angles of anterior teeth.
Class 5: caries affecting gingival one-third of facial/lingual surfaces of anterior
or posterior teeth.
Class 6: caries affecting cusp tips of molars, premolars and cusped.
2. International caries detection and assessment system(ICDAS). The ICDAS is
an evidence-based tool used to classify dental caries. Lesions are scored from
0 to 6 and the treatment recommendations are made based on the score.
score 0: sound (no evidence of caries).
score 1: early stage decay (first visual change in enamel).
score 2: early stage decay (distinct visual change in enamel).
score 3: established decay (localized enamel break down).
score 4: established decay (underlying dentin shadow).
score 5: severe decay (distinct cavity with visible dentin).
score 6: severe decay (extensive cavity with visible dentin).
3. American dental association caries classification system. To develop a new
caries classification system that could be easily adapted in clinical practice.
Sound: the dental tissue appears normal in color, translucency, and glossiness,
or the tooth has an adequate restoration or sealant with no sign of a caries lesion.
There is no change in tooth surface or adequately restored.
Initial lesions: lesions are limited to the enamel or cementum or very outermost
layer of dentin. Includes change in color to white or brown. In pits and fissures
there is a clear change in color to brown but no sign of significant
demineralization in the dentin (that is no underlying dark gray shadow). The
tooth surface is visually there is no cavity.
Moderate lesions: deeper demineralization with some possibility of enamel
surface micro cavitation, early shallow cavitation, and/or dentin shadowing
visible through the enamel, visible sign of enamel loss in pits an fissures, on
smooth surfaces or visible signs of cementum or dentin loss on the root surface.
Although the pits and fissures may appear intact (yet brown), dentin
involvement may often be detected by the appearance of a dark gray shadow of
translucency visible through the enamel. The presence and extend of lesions
cavitation cannot be assessed without the use radiographs, tooth separation or
both. The tooth surface is established, early cavities, shallow cavitation and
micro cavitation.
Advanced lesions: full cavitation through the enamel and the dentin is clinically
exposed. The tooth surface is spread or disseminated, late cavitation and deep
cavitation.
4. Common use as caries classification:
Superficial caries: caries affecting enamel layer.
Media caries: caries affecting enamel layer and half of upper dentin layer.
Profunda caries: caries affecting enamel, all dentin layer and no pulp tissue
involvement.
Profunda perforation caries: caries affecting enamel, dentin layer and including
pulp tissue. Pulp tissue is exposed according to the radiograph photo result.
2.3.1.12. Gagging Reflex
a. What is oral procedure in vomiting patient?
Gagging reflex/vomiting results from the irritation of sensitive areas in the
posterior pharyngeal wall, the soft palate, the uvula, the faucets, or the posterior
dorsal surface of the tongues. The afferent impulses that provoke the reflex
may result from tactile, visual, acoustic, olfactory, and psychic stimuli. The
vomiting or gagging reflex may be initiated also by chemical irritants which
act parasympathetic afferent terminals in the gastric mucosa.
Dental management:
1. Pharmacological therapy: Drugs may be used effectively as adjuncts in
combating gagging and vomiting where the biomechanical factors that
might induce this syndrome have been eliminated.
- These drugs are the sedatives, antihistamines, parasympatholytics, and the
central nervous system depressants, any of the barbiturates may be helpful.
- The atropine series is another group of useful drugs. These
parasympatholytic compounds reduce salivation and inhibit the vomiting
reflex.
- In very difficult gaggers, or as a temporary measure, some of the newer
central nervous system depressants employed postoperatively in general
surgery may be used. Perhaps the best known of these drugs is Thorazine
(chlorpromazine)
- Local anesthetic sprays, gels, mouth rinses, injection and glossopharyngeal
nerve block. Some study authors have criticized the use of topical or local
anesthesia for gagging but proponents suggest that if the mucosal surfaces
particularly of the soft palate are desensitized, the patient is less likely to
gaggling.
2. Non-pharmacological therapy.
- Relaxation techniques: help by reducing the anxiety state and enabling the
patient to override unhelpful thought processes.
- Distraction techniques: temporarily divert the patient’s attention and allow
to perform minor dental procedures while the mind is dissociated from a
potentially distressing situation.
- Suggestion and hypnosis: help to relax the patient and temporarily remove
or ameliorate the gag reflex to allow dental treatment to be performed.
- Ear plug technique: in this technique the ear plug acts as an external auditory
canal stimulator to suppress the profound gag reflex.
2.3.1.13.Candida Albicans
a. Swab procedure for making diagnostic of Candida albicans.
Candida species considered as one of the most important causes of human
infections. Candidacies are common infection caused by yeast-like fungus.
Candida is not harmful in healthy hosts, but may cause opportunistic infections
in immune-compromised hosts, such as patients suffering from AIDS. Several
brands of chromogenic media are available for rapid identification of yeast.
These special media yield microbial colonies with varying pigmentation
secondary substrates that react with enzymes secreted by microorganism.
These media are specific, allowing the organisms to be identified to the species
level by their color and colonial characteristics. The manufactures of CHROM
agar Candida currently advertise its product as able to detect and differentiate
many species, C albicans by growth as light to medium green colonies after
incubation for 48 hours at 37°C. Preparation of CHROM agar Candida:
CHROM agar Candida was prepared according to the manufacturer's
instructions. CHROM agar Candida is composed of (per liter): peptone
(10g), glucose (20 g), agar (15g), chloramphenicol (0.5g) and “chromogenic
mix” (2g). Twelve grams of CHROM agar Candida powder which was
added to 250 ml of sterile distilled water in a sterile Erlenmeyer flask.
The suspension was completely dissolved by boiling (<100°C) and mixing.
The medium dose not require sterilization by autoclave, therefore after
cooling in a water bath to 45°C the agar was poured into sterile petri
dishes. After allowing cooling, the plates were stored at 4°C prior to use.
Samples were obtained by swabbing oral cavity area of buccal mucosa and
tongue with a sterile cotton swab, then were plated onto sabrourad's dextrose
agar (SDA) and incubated at 37 C for 48 hours. Growth on SDA colonies were
inoculated into germ tube test. Yeast colonies growing on each SDA tube were
suspended and 10 microliter of suspension solution was used to inoculate plates
with CHROM agar candida agar medium. Inoculated plates were incubated at
37°C and read for up to 7 days. Plates were observed for fungal growth using
morphology and color to determine the presence of yeasts. As per the
manufacturer, Candida albicans, C tropicalus, C krusei and Candida glabraya
were identified by the production pf green, dark blue, pink and pink with a
darker mauve center colures colonies, respectively.
2.3.1.14.Upper Respiratory Tract Infection

a. The impact of active smoking on oral health
Smoking is also one of the major risk factors for oral diseases such as
periodontal diseases, oral precancerous & oral cancer.
1. Periodontal diseases, including gingivitis and periodontitis, are common
human bacterial infections that affect the gingiva and bone supporting the
teeth. Disease severity increases with the frequency of smoking. Smoking
is also associated with an increased risk of periodontal attachment loss and
formation of periodontal pockets, as well as alveolar bone loss (Fig 1). The
adverse effects of smoking on the periodontium correlates well with both
the quantity of daily consumption and the duration. Smokers were recorded
to have a 2.5 to 3.5 time’s greater risk of severe periodontal attachment loss.
In addition, emotional stress and poor oral hygiene seem to play an
important interactive role with tobacco smoking.
2. Smokers with oral premalignant lesions such as leukoplakia and
erythroplakia (red patches or plaques that cannot be characterized clinically
or pathologically as any other conditions) have an annual cancer
transformation rate of about 5% (Fig 4). Stopping smoking may reduce the
number of leukoplakia cases by 36%, while elimination of betel nut
influence may prevent 62% cases of leukoplakia and 26% of cases of
malignant transformation to oral carcinoma.
3. Oral cancer is dominated by squamous cell carcinoma (present in 90%-95%
of all oral cancers), and the role of tobacco in the development of oral
squamous cell carcinoma is well recognized (Fig 5). Tobacco smoking and
betel nut chewing with or without smokeless tobacco use may induce
mutations in p53 and Rb tumor suppressor genes. Glutathione S-transferase
M1 (GSTM1) and T1 (GSTT1) enzymes are both involved in the
metabolism of environmental carcinogens, including tobacco derived
carcinogens. The prevalence of null genotypes of GSTM1 and GSTT1 is
high among cases of oral cancer, with both null genotypes occurring
together in 60.2% of cases in one study.
2.3.1.15.Virus
Virus-specific Post-exposure Management
1. HIV: Use of post-exposure prophylaxis can help to reduce the risk of
contracting HIV. Maximal benefit can be obtained by initiating treatment
within hours of exposure. Guidelines include the following: Start post-
exposure prophylaxis as soon as possible. Reevaluate the exposed individual
within 72 hours, particularly focusing on new information regarding the source
and the exposure. If the source is determined to be HIV-negative, post-
exposure prophylaxis can be discontinued. If the source is determined to be
HIV-positive, continue treatment for 4 weeks if tolerated. All workers exposed
to HIV should undergo HIV antibody testing at 6 weeks, 12 weeks, and 6
months. A few additional considerations regarding HIV exposure
management: There is the possibility of toxicity with antiretroviral, so use
should be restricted to exposures in which reasonable risk of transmission is
present. Drug therapy (with 2 nucleoside analogues) is recommended, although
3-drug therapy may be warranted under certain circumstances (i.e., a source
with a high viral load or known drug resistance).One should inform the treating
physician about pregnancy status and current medications because these can
influence the selection of a treatment regimen.
2. HBV: The treatment after exposure varies based on the vaccination status of
the exposed individual and the HBV status of the patient : Regardless of the
status of the patient, if an individual suffers a needle stick and is unvaccinated,
the vaccination series should be initiated. If an individual has been vaccinated
and has a documented response to the vaccine, then no treatment is required
after an exposure. If the vaccination status of the exposed individual is
unknown, he or she should be tested for anti-HBs before deciding on treatment.
3. HCV: No treatment has been shown to prevent infection for workers
exposed to HCV. Recommendations center on following workers after the
injury and monitoring for HCV RNA in the serum. Recommendations
include: Begin testing for HCV antibodies, HCV RNA levels, and alanine
aminotransferase (ALT) levels immediately after the event. Repeat testing
2-8 weeks later. If infection occurs, the health care worker should be
referred to a specialist for management.
2.4. Poli Anak RSD Balung

2.4.1. Jenis SPM
SPM rawat jalan di bagian poli anak, dan SPM rawat inap di ruang
Perinatologi dan ruang anak Dahlia
2.4.2. Kegiatan
a. Observasi prosedur penegakan diagnosis/DD serta menetapkan rencana
perawatan
b. Identifikasi fokus infeksi pada pasien dengan berbagai
penyakit/kelainan antara lain:
1) Pasien dengan cleft lip dan cleft palatum, disertai dengan
hemangioma pada paha atas kiri dan hidrosefalus
2) Hipertensi pada pasien anak
3) Epilepsi pada pasien anak
4) Pasien anak dengan keadaan kulit menguning yang perawatan
selanjutnya adalah pemberian paparan sinar biru.
5) Bronchiolitis pada anak (rawat inap)
6) Trombositopeni pada anak (rawat jalan)
c. Edukasi orang tua pasien untuk menjaga kebersihan rongga mulut bayi
yang aktif konsumsi ASI.
d. Edukasi kepada orang tua dan anak cara memilih sikat dan cara gosok
gigi pada anak yang mengalami trombositopeni karena memiliki faktor
resiko perdarah pada gusi jika salah dalam pemilihan sikat gigi dan cara
menggosok giginya.
2.4.3. Capaian
a. Mampu mengedukasi orang tua pasien untuk menjaga kebersihan
rongga mulut bayi yang aktif konsumsi ASI, sehingga orang tua pasien
dapat mempraktekkannya.
b. Mampu mengedukasi kepada orang tua dan anak cara memilih sikat dan
cara gosok gigi pada anak terutama pada anak yang mengalami
trombositopeni karena memiliki faktor resiko perdarahan pada gusi jika
salah dalam pemilihan sikat gigi dan cara menggosok giginya
2.4.4. Obyek Garapan
a. Pasien
b. Alat medis
2.4.5. Uraian / diskripsi kegiatan yang dikerjakan
Cara pemeliharaan kesehatan gigi dan mulut pada anak usia balita
a. Bayi usia 0 – 6 bulan
1. Memberikan informasi tentang masa pertumbuhan dan erupsi gigi
pada orang tua.
2. Menilai risiko untuk penyakit gigi dan mulutpada anak dengan
mengiden fikasi indikator risiko sebagai berikut:
a) Adanya riwayat penyakit gigi berlubang/karies pada anggota
keluarga.
b) Pemberian susu botol pada anak sebelum tidur.
c) Pembersihan gigi dan mulut yang tidak rutin dan tidak benar.
3. Menganjurkan cara pembersihan gigi yang tepat dan benar secara
teratur. Pada gigi yang baru erupsi dapat digunakan kain yang
lembut dan lembab.
4. Menganjurkan untuk tidak memberikan susu botol pada anak pada
Waktu tidur.
5. Menganjurkan untuk tidak menambah rasa manis pada susu botol.
6. Menganjurkan penggunaan gelas sebagai penggan botol setelah
anak dapat minum dari gelas pada usia kira-kira 12 bulan.
7. Membersihkan rongga mulut bayi dengan kassa dan air hangat
dengan cara:
a) Basahi kain kasa dengan air matang hangat, lalu balut pada jari
telunjuk Anda. Letakkan bayi di pembaringan agar Anda lebih
mudah membersihkan mulutnya. Mulailah membersihkan
mulut dari bagian luar, yaitu bibir dan sekitarnya.
b) Dengan bantuan jari tangan Anda, buka mulut bayi kemudian
masukkan jari telunjuk Anda dan gosok perlahan gusi mulai
dari bagian belakang atas hingga ke depan atas. Setelah selesai,
bersihkan gusi bagian bawah dari belakang terus ke depan.
c) Jangan lupa bersihkan lidah bayi. Lakukan mulai dari pangkal
lidah (ingat, jangan terlalu ke belakang), lalu perlahan-lahan
ke bagian depan.
Gambar 2.8. Cara membersihkan gigi dan gusi bayi
b. Bayi usia 7 – 12 bulan

Pada usia 7 – 12 bulan gigi seri atas dan bawah telah tumbuh. Beberapa
hal yang harus dilakukan oleh tenaga pelayanan kesehatan:
1. Memberikan informasi anak usia 0 - 6 bulan seperti diatas.
2. Menilai risiko untuk penyakit gigi dan mulut pada anak dengan
mengiden fikasi indikator risiko sebagai berikut:
a) Adanya riwayat penyakit gigi berlubang pada anggota keluarga.
b) Pemberian susu botol pada anak sebelum tidur.
c) Sering mengonsumsi makanan manis dan lengket.
d) Pembersihan gigi dan mulut yang tidak rutin dan tidak benar.
e) Pemberian fluor yang tidak adekuat.
3. Jika terdapat white spot(bercak putih) pada gigi:
a) Menganjurkan penggunaan gelas sebagai penggan botol setelah anak dapat
minum dari gelas pada usia kira-kira 12 bulan.
b) Menganjurkan kepada ibu atau pengasuh untuk mulai membersihkan gigi
anak segera setelah gigi mulai erupsi.
c) Menganjurkan pemberian makanan bergizi dan membatasi pemberian
makanan manis pada anak di antara dua waktu makan.
Cara menyikat gigi yang benar pada anak :
Gambar 2.9. Cara membersihkan gigi dan gusi
a. Menyiapkan sikat gigi dan pasta yang mengandung Fluor ( salah satu zat
yang dapat menambah kekuatan pada gigi ). Banyaknya pasta kurang lebih
sebesar sebutir kacang tanah (1/2 cm )
b. Berkumur-kumur dengan air bersih sebelum menyikat gigi
c. Seluruh permukaan gigi disikat dengan gerakan maju mundur pendek-pendek
atau memutar selama ± 2 menit ( sedikitnya 8 kali gerakan seƟap 3
permukaan gigi )
d. Berikan perhaan khusus pada daerah pertemuan antara gigi dan gusi.
e. Lakukan hal yang sama pada semua gigi atas bagian dalam. Ulangi gerakan
yang sama untuk permukaan bagian luar dan dalam semua gigi atas dan
bawah.
f. Untuk permukaan bagian dalam gigi rahang bawah depan, miringkan sikat
gigi seperti dalam gambar no.5. Kemudian bersihkan gigi dengan gerakan
sikat yang benar.
g. Bersihkan permukaan kunyah dari gigi atas dan bawah dengan gerakan-
gerakan pendek dan lembut maju mundur berulang-ulang.
h. Sikatlah lidah dan langit-langit dengan gerakan maju mundur dan berulang-
ulang.
Leaftlet
KELOMPOK A1
KELOMPOK A2
KELOMPOK B1
KELOMPOK B2
KELOMPOK C1
KELOMPOK C2
2.5. Instalasi Gawat Darurat (IGD) RSD Balung
Pada saat jaga di Instalasi Gawat Darurat (IGD), dilakukan berdasarkan shift
dari Rumah Sakit Daerah (RSD) Balung. Ada 3 kali pergantian shift dalam sehari
yaitu pukul (07.00-14.00), (14.00-20.00), dan (20.00-07.00). IGD di RSD Balung
memiliki satu dokter jaga dan tiga perawat dalam setiap shift jaganya.
Pada saat di IGD kami melakukan hal-hal berikut:
1. Observasi pasien yang datang.

Selama di IGD RSD Balung kami melakukan observasi tentang tahap-tahap
penanganan pasien-pasien yang datang yaitu
a. Tindakan atau penanganan pertama terhadap pasien yang dilakukan oleh
perawat. Perawat menanyakan pada wali atau keluarga pasien tentang apa
yang dikeluhkan pasien, cek kesadaran pasien, kemudian melaporkan ke
dokter jaga.
b. Pemeriksaan yang dilakukan oleh dokter jaga. Dokter memeriksa pasien
apakah termasuk pasien gawat darurat. Apabila tidak termasuk, pasien
dirujuk ke poli rawat jalan untuk dilakukan pemeriksaan lebih lanjut.
c. Pemeriksaan tanda-tanda vital
d. Pengambilan sampel darah pasien yang kemudian salah satu wali atau
keluarga pasien mengirimkan ke laboratorium untuk dilakukan pengecekan.
e. Pemasangan infus
f. Pengiriman ke bagian rawat inap/ dirujuk ke RS yang memiliki fasilitas
lebih lengkap.
2. Melakukan pengecekan tanda-tanda vital pada pasien yang datang.
Pasien yang datang di IGD RSD Balung dilakukan pengecekan tanda-tanda
vital sebelum dilakukan tindakan selanjutnya. Tanda-tanda vital yang diperiksa
antara lain tekanan darah, nadi, respirasi, dan suhu tubuh.
3. Menjadi asisten pada saat penanganan pada pasien
Pada saat perawat melakukan penanganan seperti penanganan luka, kami
membantu untuk menjadi asisten. Salah satu kasus yang kami temukan yakni
pasien dengan kondisi tangan luka sampai tendon putus. Pertama, dilakukan
asepsis yakni membersihkan bagian sekitar tangan yang luka. Setelah itu
melakukan anastesi dan dilanjutkan mencari tendon yang putus untuk
disambung kembali. Penjahitan tendon dilakukan kemudian penjahitan
jaringan setelah itu penjahitan kulit. Setelah itu, pasien diberikan suntikan
tetanus dan diberi obat minum analgesic/pereda nyeri.
Selain itu kami menjadi asisten pada saat heacting luka pada pasien post
kecelakaan lalu lintas. Terdapat 3 pasien yang harus mendapat penanganan.
Sesuai dengan triase, kami melakukan perawatan pertama pada pasien yang
mengalami cidera paling parah. Pada pasien tersebut dilakukan heacting situasi
pada area kepala belakang Dan dilakukan pemasangan kasa pada kepala pasien
yang mengalami cidera cukup parah. Setelah pasien ditangani, kami melakukan
perawatan luka pada pasien kedua dan ketiga sambil menunggu persiapan
pasien pertama untuk dirujuk ke RS Soebandi selesai.
4. Belajar cara memasang infus, kateter, dan elektrokardiogram (EKG)
Kami ikut melihat dan belajar bagaimana cara pemasangan infus, kateter,
dan elektrokardiogram (EKG) pada pasien yang dilakukan oleh perawat. Salah
satu dari kami juga ikut memasang infus, kateter dan EKG dengan didampingi
oleh perawat.
a. Memasang infus set pada kantung infus :
1) Buka tutup botol cairan infus.
2) Tusukkan pipa saluran udara, kemudian masukkan pipa saluran infus.
3) Tutup jarum dibuka, cairan dialirkan keluar dengan membuka kran
selang sehingga tidak ada udara pada saluran infus, lalu dijepit dan
jarum ditutup kembali. Tabung tetesan diisi sampai ½ penuh.
4) Gantungkan kantung infus beserta salurannya pada tiang infus.
Setelah infus terpasang pada tiang, kemudian lengan penderita bagian

proksimal dibendung dengan torniket Kenakan sarung tangan steril,
kemudian lakukan desinfeksi daerah tempat suntikan. Jarum diinsersikan ke
dalam vena dengan bevel jarum menghadap ke atas, membentuk sudut 30-
40o terhadap permukaan kulit. Bila jarum berhasil masuk ke dalam lumen
vena, akan terlihat darah mengalir keluar. Turunkan kateter sejajar kulit.
Tarik jarum tajam dalam kateter vena (stylet) kira-kira 1 cm ke arah luar
untuk membebaskan ujung kateter vena dari jarum agar jarum tidak melukai
dinding vena bagian dalam. Dorong kateter vena sejauh 0.5 – 1 cm untuk
menstabilkannya. Tarik stylet keluar sampai ½ panjang stylet. Lepaskan
ujung jari yang memfiksasi bagian proksimal vena. Dorong seluruh bagian
kateter vena yang berwarna putih ke dalam vena. Torniket dilepaskan.
Angkat keseluruhan stylet dari dalam kateter vena. Pasang infus set atau
blood set yang telah terhubung ujungnya dengan kantung infus atau kantung
darah. Penjepit selang infus dilonggarkan untuk melihat kelancaran tetesan.
Bila tetesan lancar, pangkal jarum direkatkan pada kulit menggunakan
plester. Tetesan diatur sesuai dengan kebutuhan. Jarum dan tempat suntikan
ditutup dengan kasa steril dan fiksasi dengan plester.
b. Pemasangan kateter pada pasien.
Pemasangan kateter dilakukan pada pasien perempuan berusia 65
tahun. Pertama-tama mengucapkan salam, memperkenalkan diri,
menjelaskan pada pasien dan keluarga tentang prosedur dan tujuan tindakan
yang akan dilaksanakan, apabila menyetujui membuat kontrak (waktu,
tempat dan tindakan yang akan dilakukan).
Tahapan-tahapan yang dilakukan :
1) Pasien diberi penjelasan tentang prosedur yang akan dilakukan,
kemudian alat-alat didekatkan ke pasien
2) Pasang sampiran
3) Cuci tangan
4) Pasang pengalas/perlak di bawah pantat klien
5) Pakaian bagian bawah pasien dikeataskan/dilepas, dengan posisi pasien
lithotomi (kaki ditekuk dan kaki sedikit dibuka). Nierbekken diletakkan
di dekat pantat pasien.
6) Buka bak instrumen, pakai sarung tangan steril, pasang duk steril, lalu
bersihkan alat genitalia dengan kapas sublimat dengan menggunakan
pinset.
7) Bersihkan genitalia dengan cara: dengan tangan nondominan perawat
membuka vulva kemudian tangan kanan memegang pinset dan
mengambil satu buah kapas sublimat. Selanjutnya bersihkan labia
mayora dari atas kebawah dimulai dari sebelah kiri lalu kanan, kapas
dibuang dalam nierbekken, kemudian bersihkan labia minora, klitoris,
dan anus. Letakkan pinset pada nierbekken
8) Ambil kateter kemudian olesi dengan jelly. Masukkan kateter kedalam
uretra kira-kira 10 cm secara perlahan-lahan dengan menggunakan
pinset sampai urine keluar. Masukkan cairan Nacl/aquades 20-30 cc
atau sesuai ukuran yang tertulis. Tarik sedikit kateter. Apabila pada saat
ditarik kateter terasa tertahan berarti kateter sudah masuk pada kandung
kemih
9) Lepaskan duk, sambungkan kateter dengan urine bag. Lalu ikat disisi
tempat tidur
10) Fiksasi kateter pada bagian sisi dalam paha klien
11) Pasien dirapihkan kembali
12) Alat dirapihkan kembali
13) Mencuci tangan.
c. Pemasangan elektrokardiogram (EKG)
Langkah-langkah pemasangan EKG :
1) Atur posisi pasien, posisi pasien diatur terlentang datar
2) Buka dan longgarkan pakaian pasien bagian atas, bila pasien memakai
jam tangan, gelang, logam lain agar dilepas
3) Bersihkan kotoran dengan menggunakan kapas pada daerah dada,
kedua pergelangan tangan dan kedua tungkai dilokasi manset elektroda.
4) Mengoleskan jelly pada permukaan elektroda.
5) Memasang manset elektroda pada kedua pergelangan tangan dan kedua
tungkai.
6) Memasang arde.
7) Menghidupkan monitor Elektrokardiogram.
8) Menyambungkan kabel Elektrokardiogram pada kedua tungkai
pergelangan tangan dan kedua tungkai pergelangan kaki pasien, untuk
rekaman ekstremitas lead (Lead I, II, III, AVR, AVL, AVF) dengan
cara :
a) Warna merah pada pergelangan tangan kanan
b) Warna hijau pada kaki kiri
c) Warna hitam pada kaki kanan.
d) Warna kuning pada pergelangan tangan kiri.
9) Memasang elektroda dada untuk rekaman precardial lead
a) V1 pada interkosta keempat garis sternum kanan
b) V2 pada interkosta keempat garis sternum kiri
c) V3 pada pertengahan V2 dan V4
d) V4 pada interkosta kelima garis pertengahan clavikula kiri
e) V5 pada axila sebelah depan kiri
f) V6 pada axila sebelah belakang kiri
10) Melakukan kalibrasi dengan kecepatan 25 mili/detik

11) Bila rekaman Elektrokardiogram telah lengkap terekam, semua
elektroda yang melekat ditubuh pasien dilepas dan dibersihkan seperti
semula.
12) Pasien dibantu merapihkan pakaian
d. Pengambilan sampel darah dengan didampingi perawat

Pada saat perawat melakukan pengambilan sampel darah kami
membantu untuk menjadi asisten. Pertama, jelaskan maksud dan tujuan
tentang tindakan yang akan dilakukan. Minta pasien meluruskan lengannya,
pilih tangan yang banyak melakukan aktivitas. Minta pasien untuk
mengepalkan tangannya. Pasangkan torniqket kira-kira 10 cm diatas lipatan
siku. Pilih bagian vena mediana cubiti atau cephalica. Lakukan perabaan
(palpasi) untuk memastikan posisi vena. Vena teraba seperti sebuah pipa
kecil, elastic dan memiliki dinding tebal. Bersihkan kulit pada bagian yang
akan diambil dengan kapas alkohol 70% dan biarkan kering, dengan catatan
kulit yang sudah dibersihkan jang dipegang lagi. Tusuk bagian vena dengan
posisi lubang jarum menghadap ke atas. Jika jarum telah masuk ke dalam
vena, akan terlihat darah masuk kedalam semprit (flash). Usahakan sekali
tusuk vena, lalu torniquet dilepas. Setelah volume darah dianggap cukup,
minta pasien membuka kepalan tangannya. Letakan kapas di tempat
suntikan lalu segera lepaskan / tarik jarum. Tekan kapas beberapa saat lalu
plester selama ± 15 menit.
e. Belajar prosedur merujuk pasien

Selama kami bertugas di IGD, terdapat beberapa pasien yang harus
dirujuk ke RS lain karena keterbatasan alat dan tenaga kesehatan di RSD
Balung. Dengan arahan dari perawat yang bertugas, kami belajar prosedur
merujuk pasien dan kondisi-kondisi apa saja yang mengharuskan pasien
dirujuk.
2.6. Poli Gigi RSD Balung

2.6.1. Jenis SPM
SPM rawat jalan bagian gigi dan mulut
2.6.2. Kegiatan
a. Mengevaluasi tata laksana perawatan gigi dan mulut.
b. Melakukan pengisian odontogram sebagai kelengkapan data rekam
medik pasien.
c. Observasi tatalaksana penderita dengan kompromi medis (penyakit
sistemik dengan riwayat diabetes mellitus).
d. Observasi tatalaksana pasien trauma KLL (Kecelakaan Lalu Lintas) di
poli rawat jalan gigi.
e. Observasi tatalaksana pasien trauma KLL (Kecelakaan Lalu Lintas) di
poli rawat inap (R.melati).
2.6.3. Capaian
a. Mengobservasi perlengkapan dan bagian bagian yang tersedia di rawat
jalan poli gigi.
b. Mampu mendemonstrasikan cara menganamnesis dan melakukan
pemeriksaan fisik secara umum serta menegakkan diagnosis sesuai
standart klasifikasi penyakit internasional.
c. Mampu memahami pemeriksaan penunjang sesuai tatalaksana penderita
dengan kompromi medis (penyakit sistemik dengan riwayat diabetes
mellitus).
d. Memahami cara menyusun rencana perawatan pada setiap diagnosis
dalam bilang kedokteran gigi.
2.6.4. Obyek Garapan
a. Pasien
b. Alat medis
2.6.5. Uraian / diskripsi kegiatan yang dikerjakan
a. Pasien perempuan dengan usia 58th datang ke poli gigi RSD Balung
dengan keluhan tidak nyaman dengan gigi belakang kanan atas dan
ingin mencabutkannya. Berdasarkan riwayat penyakit, pasien tersebut
diketahui memunyai riwayat penyakit diabetes mellitus. Pasien
kemudian dikonsul ke bagian laboratorium untuk dilakukan
pemeriksaan gula darah sesaat. Berdasarkan hasil pemeriksaan
diketahui pemeriksaan gula darah sesaat 260 mg/dl, sehingga tidak
dilakukan pencabutan.
b. Pasien anak anak dengan usia 9 tahun datang ke IGD dengan trauma
post KLL. Pemeriksaan objektif diketahui gigi 11,12,21,22 sudah hilang
serta laserasi pada mukosa labial rahang bawah. Dilakukan kontrol
perdarahan dengan penjahtan pada luka laserasi pada mukosa labial
rahang bawahnya. Kemudian pasien di rujuk ke rawat inap untuk
menstabilkan kondisinya. Setelah tindakan 24 jam kemudian diketahui
pasien dalam keadaan baik, dan terjadi pembengkakan pada bibir atas
dan bawah pasien. Setelah 24 jam pasien terus dimonitor untuk
mengetahui apakah pasien mengalami gegar otak atau tidak. Pasien
diizinkan untuk kemudian pulang untuk proses penyembuhan dan
melakukan foto panoramik. Obat yang diberikan aloclair sebagai obat
antiinflamasi.
c. Pasien anak anak klas 2SD datang ke poli gigi dengan trauma post KLL.
Pemeriksaan objektif diketahui gigi 11 goyang derajat 3, gigi 21 goyang
derajat 3 dan infraposisi. Gingiva1/3 servikal area 11 dan 21 berwarna
merah dan terjadi perdarahan. Perawatan yang dilakukan ada reposisi
gigi dan splinting dengan menggunakan komposit pada bagian labial
dan palatal. Obat yang diberikan berupa aloclair gel, amoxan dan asam
mefenamat.
BAB 3. MORNING REPORT
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4392 - Laporan Pembelajaran Ikk Lengkap

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LAPORAN PEMBELAJARAN

ILMU KEDOKTERAN KLINIK (IKK)

BAGIAN ILMU KEDOKTERAN KLINIK

2.1. Pencegahan dan Pengendalian Infeksi (PPI)

Central Sterilization Supply Department (CSSD) merupakan salah satu

2.1.1. Defenisi CSSD

2.1.2. Struktur Organisasi Instalasi Pusat Sterilisasi

2.1.3. Tugas Instalasi Pusat Sterilisasi

2.1.4. Sarana Fisik dan Peralatan

2.1.5. Bangunan dan Lokasi Instalasi Pusat Sterilisasi

2.1.6. Ruangan Instalasi Pusat Sterilisasi

2.1.7. Aktivitas Fungsional CSSD

2.1.8. Sistem Sterilisasi

2.1.9. Indikator Sterilisasi

2.2. Poli Bedah RSD Balung

2.3. Poli Penyakit Dalam RSD Balung

c. Oral manifestation of hypertension

2. Salivary Gland dysfunction

Fig 2.8. Periodontitis

2.3.1.10. Thyroid Carcinoma

2.3.1.11. Dental Caries

2.3.1.14.Upper Respiratory Tract Infection

2.4. Poli Anak RSD Balung

b. Bayi usia 7 – 12 bulan

Pada saat di IGD kami melakukan hal-hal berikut:

1. Observasi pasien yang datang.

Setelah infus terpasang pada tiang, kemudian lengan penderita bagian

10) Melakukan kalibrasi dengan kecepatan 25 mili/detik

d. Pengambilan sampel darah dengan didampingi perawat

e. Belajar prosedur merujuk pasien

2.6. Poli Gigi RSD Balung

Batool SN, Ablollah R and Fereshteh M. 2011. Prevalence of Candida species in

C Manikandan & A. Amsath. 2013. Isolation and Rapid Identification pf Candida

Carolyn Chu and Peter A. Selwyn. 2015. Complications of HIV Infection: A

Cringuta P, Christina G. 2011. Oral Manifestations in Liver Diseases. Romanian

G.A, Bartholome. 2013. Oral candidiasis in patient with Diabetes mellitus.

Kumar P, dkk. Oral manifestations in hypertensive patients: A clinical study. 2012

Little and Falace’s. 2013. Dental Management of medically compromised patient

Martin greenberg, burket's oral medicine, rosa maria, xerostomia, hyposalivation

Medullary thyroid carcinoma: diagnostic potential by Gayle Nelson, Pediatric

Newman, et al. 2012. Carranza Clinical Periodontology 12th edition. China:

Olive A, Salavert A, Monriquez M, Clotet B, Maragos A. 1998. Parotid

Panchbhai, A. 2015. Oral Considerations in Diabetes Mellitus. India: Sharad Pawar

Plemons, et al. 2015. Managing xerostomia and salivary gland hypofunction: A

Romano and Cardile. 2014. Gastroesophageal reflux disease and oral

Sanda Mihaela. 2013. hypersensitive patient and their management in dentistry.

Suvarna R, Rao P. 2017. Oral Manifestation in Chronic Liver Failure. Austin

Thyroid cancer basics by Thyca: Thyroid cancer survivors association, inc.

Thyroid carcinoma metastasising in the mandible: a case report by Ksitiz Rohilla,

Topley and Wilson. 2005. Microbiology and Microbial Infections: Medical

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