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Laporan Jaga Ppok

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    LAPORAN JAGA01 Juni 2016

    Seorang Pria 58 tahun dengan SesakNapas

    Deasy Silvia L H2A01101

    !"PAN#$"%AAN !L#N#! #L&' P"N(A!#$

    DALA&%S'D D%) ADH(A$&A* &PH S"&A%AN+ , -!'N#&'S

    201.

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    Nama : tn. Supriyanto

    Usia : 58 taun A!ama : "s#am

    A#amat : Sri $un%oro &a#i'ant(n! S(maran!

    Status : )(ni$a

    *an!!a# masu$ : 01 Juni 2016

    "+(ntitas Pasi(n

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    &(#uan Utama : S(sa$ Napas

    RPS

    1. Lo$asi : +a+a2. Ons(t +an $rono#o!is :

    , 2 min!!u S)RS pasi(n m(n!(#u s(sa$napas. S(sa$ yan! +irasa saat pasi(n

    s(+an! m(ro$o$. Pasi(n masi 'isa'(ra$ti-tas s(p(rti 'iasa. S(sa$ yan!+irasa$an s(ma$in #ama s(ma$in '(rat.

    )RS pasi(n m(rasa tam'a s(sa$. A$ti-tas

    pasi(n m(n/a+i t(r'atas.

    Anamn(sa

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    . &uantitas : s(sa$ t(rus m(n(rus

    . &ua#itas : s(sa$ m(n!!an!!u a$ti-tas

    5. a$tor m(mp(r'(rat : tam'a s(sa$ 'i#apasi(n '(r/a#an +an '(r'arin!

    6. a$tor m(mp(rin!an : s(sa$ '(r$uran! 'i#apasi(n +u+u$

    3. G(/a#a #ain : 'atu$ '(r+aa$ +(n!an +aa$'(r4arna $unin! +aa$ susa $(#uar#(mas 7. 9a' 7 norma# 9A& 7 #an%arpusin! +(mam $(rin!at +in!in

    +ima#am ari .

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    Ri4ayat P(nya$it ;au#u :

    1. Ri4ayat $(#uan yan! sama : ;isan!$a#

    2. Ri4ayat asma : ;isan!$a#

    . Ri4ayat ;) : ;isan!$a#

    . Ri4ayat * : ;isan!$a#

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    Ri4ayat Sosia# = >$onomi :

    Pasi(n '($(r/a s('a!ai $on+($tur 'us. Pasi(ns(oran! p(ro$o$ +(n!an /um#a ro$o$ yan!+iisap p(rari 12 'atan!. Pasi(n m(ro$o$su+a , 0 taun. Pasi(n tin!!a# '(rsama istri+an $( ana$nya. 9iaya p(n!o'atan +(n!an9PJS. &(san ($onomi %u$up.

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    Anamn(sis Sist(mis :

    1. &u#it : $(rin!at +in!in

    2. &(pa#a : pusin!

    . )ata : pan+an!an $a'ur

    . *(#in!a : p(n+(n!aran '(r$uran! '(r+(n!in!

    5. )u#ut : 'i'ir $(rin!

    6. L((r : ny(ri t(#an

    3. Sist. R(spiras : s(sa$ napas 7 'atu$'(r+aa +(n!an +aa$ '(r4arna $unin!7

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    8. Sist. &ar+io?as : '(r+('ar ny(ri +a+a

    @. sist. P(n%(rnaan : ny(ri p(rut 9A9 7

    norma#10.Sist. P(r$(mian : 9A& 7 norma#

    11.)us$u#os$(#(ta# : ny(ri otot p(!a#

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    &(a+aan umum : tampa$ sa$it s(+an! +an tampa$s(sa$ tripot position 7

    &(sa+aran : ompos )(ntis GS >B )C DE

    *an+a Dita# :

    *;: [email protected]

    N : 110 Fmnt isi H *(!an!anH

    RR: 28 Fmnt

    * : 68 I ai#(r Status !ii :

    99 : 56 $!

    *9 : 16

    ")* : 215 normo4(i!t

    P(m(ri$saan isi$

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    S$a#a Ny(ri : 5

    Risi$o /atu )ors( a## S%or( :

    Ri4ayat /atu : ti+a$ 0 ;ia!nosa s($un+(r : ti+a$ 0

    A#at 'antu : ti+a$ 0

    *(rpasan! inKus : a 20

    Status m(nta# : sa+ar p(nu 0 Gaya '(r/a#an : norma# 0

    Ni#ai M 20 risi$o r(n+a

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    &u#it : tampa$ $(m(raan

    &(pa#a : tur!or $u#it +ai 2 +(ti$

    )ata : A F S" F r(($ pupi# 7F7iso$or mmFmm 9R mata %($un! F

    *(#in!a : %airan

    i+un! : %airan napas %upin! i+un!

    )u#ut : sianosis pu#s(#ips 'r(atin!7

    L((r : p(m'(saran &G9 p(n!!unaanotot 'antu napas 7

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    *ora$ :

    pu#mo :

    "nsp($si : p(r!(ra$an +a+a statis+inamissim(tris tampa$ 'arr(# %(st tampa$ s(#ai!a m(#('ar r(tra$si 7

    Pa#pasi : ny(ri t($an s(#a i!a m(#('ar

    Kr(mitus m(#(ma P(r$usi : ip(rsonor

    Aus$u#tas : suara +asar ?asi$u#(r m(n/auron$i 7F7 pasa ($spirasi.

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    or :

    "nsp($si : i%tus %or+is ta$ tampa$

    Pa#pasi : i%tus %or+is t(ra'a +i "S 5 $uatan!$at ti+a$ m(#('ar

    P(r$usi : $(san 'atas /antun! ti+a$ m(#('ar

    Aus$u#tas : suara /antun! "Q"" 'isin!

    /antun!

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    A'+om(n :

    "nsp($si : '(ntu$ p(rut norma# p(rmu$aan +atar

    Aus$u#tas : 'isin! usus 7 norma# 18 P(r$usi : timpani +is(mua #apan! a'+om(n

    Pa#pasi : ny(ri t($an ti+a$ t(ra'ap(m'(saran or!an

    >$str(mitas :

    A$ra# +in!i : F

    O(+(m : F

    Sianosis : F

    R* : 2 +t$ F 2 +t$

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    ;ara Rutin :

    L(u$osit : 132

    >ritrosit : 5 ' : 16

    t : 63

    )D : 8180

    ) : 280 ) : 580

    *rom'osit : 20

    P(m(ri$saan P(nun/an!

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    ANA&N"SA P"&"%#!SAAN-#S#!

    P"N'N/AN+

    1. S(sa$ napas

    2. 9atu$ '(r+aa$'(r4arna $unin!. A$ti-tas

    t(r'atas. P(ro$o$5. 9($(r/a s('a!ai

    $on+($tur 'us

    6. &U tampa$ sa$it

    s(+an!3. $u#it $(m(raan8. Pu#s(#ips

    'r([email protected] Otot 'antu

    napas

    10.9arr(# %(st11.S(#a i!am(#('ar

    12.r(mitusm(#(ma

    1.ip(rsonor

    1.Suara +asar?asi$u#(r

    16.L(u$ositosis

    ;ata A'norma#

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    An#isis )asa#a

    1. susp. PPO& :

    [email protected]

    Pro'#(m

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    PPO&

    1. Ass(sm(nt PPO&

    R(n%ana P(m(%aan

    )asa#a

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    2. "nitia# P#an

    a. ;ia!nosis :

    .aa# Paru

    .;ara rutin

    .Ra+io#o!i Koto *ora$ posisi APFL

    '. *(rapi :

    .O$si!(nasi +(n!an nasa# $anu#

    . "nKus RL 7 +rip amino-#in 2 m! 20 tpm

    .N('u#i(r %om'i?(nt 7 pu#mi%ort 1:1

    . "n/. )(ti#pr(+niso#on 2 amp

    . "n/. (Kotaim 21 amp

    .Am'roo# 0 m! 1

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    %. )onitorin! :

    .&(a+an umum

    .*an+a ?ita#

    .O's(r?asi $(#uan p(rnapasan

    +. >+u$asi :

    .9(r(nti m(r($o$

    .)(n!in+ari p(n%(tus m(ma$ai mas$(r

    .)inum o'at s(%ara t(ratur s(suai an/uran +o$t(r.)(n!(taui tan+a ($sas(r'asiF$($am'uan

    'atuFs(sa$ napas sputum '(rtam'a sputum'(ru'a 4arna

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