POMR Gangren [PDF]

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POMR (Problem Oriented Medical Record) Name Age



: Tn.Abd Muntolib : 60 th CLUE AND CUE



DATA BASE Tn.Abd Muntolib 60 th KU: luka di pergelangan kaki kiri sejak 4 hari yll Anamnesis: • Keluhan dirasa sejak hari yll, penderita duduk dikursi bambu, kemudian pada pergelangan kaki kiri terkena paku • RPD: DM • Rpk : DM Pemeriksaan fisik: • T=140/100mmHg,Nadi= 84x/mnit reguler, t=38,5°C, GCS 456t, TB= 166 cm, BB=70 kg • Abdomen: liver dan limpa tidak teraba, bising usus normal • Ekstremitas: Ulkus pedis sinistra pus +, nekrotik +, bau menyengat +, gringgingan, oedem Laboratorium • GDA 502 mg/dl



Laki2 60 th Ulkus pedis sinistra, pus, nekrotik, riwayat DM GDA 502 mg/dl



PROBLEM LIST 1. Ulkus di kaki



Laki2 60 th DM



2. DM



Laki2 60 th DM, gringgingan



3. Neuropa



INITIAL DX 1.1 Ulkus diabetic



DIAGNOSIS Cek GDA



GDA, GD2PP, GDP



PLANNING THERAPY MONITORING pus, sansulin R 4 U/jam  4 x Ulkus, Sansulin R 3x10 U SC nekrotik, bau sblm makan PZ 20 tetes/menit Ceftriaxon 2x1 g Metronidazol 3x500 g tab Diet B 2100 kal Debridement



GDA, GDP



GD2PP,



EDUCATION Hygiene life syle



Life style



2.1 DM Tipe 2 2.2 DM Tipe 1



Nyeri +/ti perifer



Pmx fisik saraf 3.1 neuropati sensorik 3.2 neuropati motorik 3.3 nuropati autonomik



Life style Monitoring gula darah



SOAP SUBJECTIVE 5 maret 2011 luka di kaki, oedem



6 maret 2011 luka di kaki, oedem 7 maret 2011



OBJECTIVE



ASSESMENT



PLANNING



Ulkus



Diabetic foot, MODS, sepsis



Dx : konsul ke spesialis bedah, cek GDA Tx : sansulin R 4 U/jam  4 x Sansulin R 3x10 U SC sblm makan PZ 20 tetes/menit Ceftriaxon 2x1 g Metronidazol 3x500 g tab Diet B 2100 kal



T: 140/80 mmHg, t: 36,6 C, N: 88 x/menit, GDA: 274 mg/dL



Diabetic foot, MODS, sepsis



Dx : foto pedis Tx : due to one Debridement