Selamat Menunaikan Ibadah Puasa

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CHAPTER III EVALUATE CASE



 A. the Client Identity :
 Name : Bp. S
 Age : 58 year
 Religion : Islam
 Gender : Man - man
 Address : Purworejo - Pasuruan
 B. the Especial Sigh
 Moment MRS ( 21 Februari 2005)
 and pain in bone [of] [at] hurt of back of [his/its] right heel and foot/feet. Pain in bone felt to [by] come up with right calf
 Study Moment ( 28 Februari 2005)
 Client tell back of [his/its] right foot/feet felt [by] a pain in bone. Pain in bone bent the mind to [by] hurt area. Pain in bone felt especially the moment move foot/feet / removing place. Client lay open scale of [his/its] pain in bone 5
 C. Medical Diagnosa : Ganggren Diabeticum Pedis
 D. History of Disease Now :
 Wife of Client tell hurt of foot/feet of client [of] initially only the chafed hurt minimize. In process of time that hurt extend and swell. Hot client also and by [his/its] wife [is] brought [by] kedokter. Hot [of] client descend but [his/its] hurt is not good. Later;Then the client brought again kedokter and suggested for MRS. Client of MRS [of] [at] date of 18 Februari 2005 [in] RS Pasuruan. Because hurt of client [do] not the goodness, family of client ask to move RS, client made reference to [by] Unlucky RS lavalette [at] date of 21 Februari 2005. Client of MRS with sigh of mual-muntah and pain in bone [of] [at] hurt dipergelangan Client get medication of compress of betadine and hurt closed [by] kassa. Client tell [his/its] hurt [is] felt [by] pain in bone [of] like ditusuk-tusuk. Pain in bone felt [at] shares of hurt that is [at] back of right foot/feet, pain in bone [do] not menjalar. Client tell is not delicious eat and only finish semi portion eat nya
 E. History of disease ago
 Client tell to suffer diabetes [of] since year 1996. During the time rate of sugar in blood of mean client < 200 gr / dl. Diligent client also kontrl kedokter and obey diet which have been determined. Client tell less sukja berolah raga. Client tell x'self of smoker hitherto still smoke
 F. History of family health
 In family of client [of] there are DEUTSCHMARK history. Sister of Client die because DEUTSCHMARK in the year 2000 ago and uncle of client also meniggal [of] because decameter also in the year 2002
 G. History psikososial
 Client [is] pensioner of health worker. Client work as expert immunize since year 1965 and retired since 2 year ago. Though have pension. Client still be asked to assist to immunize [at] some house copy. [relation/link] of Client with good environment and family, client have 4 putra which is all the nya of sedah keep house. During MRS [in] Lavalette of client [is] always accompanied by [his/its] wife.
 RS, client made reference to [by] Unlucky RS lavalette [at] date of 21 Februari 2005. Client of MRS with sigh of mual-muntah and pain in bone [of] [at] hurt dipergelangan of [his/its] right foot/feet, pain in bone felt to [by] come up with beti. During [in] RS Lavalette of client get treatment of hurt 1 X / day and therapy for padsien DEUTSCHMARK. Until the study moment, hurt of client [of] there are back of foot/feet and heel. circumstance of Hurt of back of foot/feet as long as 7 cm, hurt of chromatic
H. Pattern of everyday activity
 No of[is Breakdown Of Before MRS MRS
 1 Dilution of Client [do] not drink sugary beverage. Client drink white water 1,2 litre / day of Client drink white water as much 1,2 litre / day
 2 Food of Client eat according to therapy of DEUTSCHMARK of frequency 3 X / day consisted of [by] rice 6 spoon, lauk, client less take a fancy to vegetable of Client get diet of DEUTSCHMARK 3 X / day, client only finish ½ portion of [his/its] food
 3 Pattern Sleep Client often sleep day start at 10.00 - 12.00. Client sleep night 7-8 clock / day. Client [do] not experience of trouble sleep Client earn sleep with well-sleep 6 - 8 clock / nocturnal day
 4 Personal Hygiene of Client take a bath 2 X / day, rub tooth [of] every used up eat, keramas 2 X / week. All [done/conducted] [by] xself. Client take a bath 2 X / day with warm water wiped by family
 5 Eliminasi of CHAPTER 1 - 2 X perhari with soft consistency [of] colour yellow chocolate. BASIN 6 - 7 X perhari with colour yellow clear [of] Client of BASIN as much 5 X perhari of colour yellow clear assisted by [his/its] wife by using pispot. Client of CHAPTER 1 X / day with soft consistency [of] colour yellow chocolate
 RS Lavalette of client get treatment of hurt 1 X / day and therapy for padsien DEUTSCHMARK. Until the study moment, hurt of client [of] there are back of foot/feet and heel. circumstance of Hurt of back of foot/feet as long as 7 cm, hurt of chromatic of kemerahanpada [of] part of edge,
K. Physical Examination 1. Generality : Enough Awareness of Compos Mentis GCS : 456 2. Sign - Vital Sign
 Nadi : 88 X / minute RR : 20 X / Temperature minute : 37 oC
 Tension : 140 / 90 mm Hg 3. Lead and the Neck : Circular Head, spreading of hair flatten, black colour, Blood [of] [there] no, [do] not [is] easy to abstracted, [there] no lesion. Form ellipse face, face of grimace of moment move [his/its] right foot/feet, [do] not turn pale. Symmetrical eye, konjungtiva [do] not anemis; Sklera [do] not ikterik, [do] not there are blood. nose of Position septum of symmetrical rice, exhalation of lobe of nose [of] [there] no, blood [of] [there] no. mouth of damp Lip, [do] not sianosis, blood [of] [there] no, tooth of brass chromatic, and a lot have single, blood of gum [of] [there] no, clean mouth, odourless. [Is] not happened [by] trouble of hearing and eyesight. [At] Neck [of] [there] no magnification of vena jugularis. Position of symmetrical Trakhea 4. Integumen : Turgor return < 1 second, warm akral, colour of brownish husk, pigmentation of husk flatten 5. chest And Thorax : Form normal chest [of] chest ; Retraksi Inter costa [of] [there] no. [At] percussion got [by] voice sonor / deaf. Auskultasi : Vesikuler [of] all spacious [of] paru
 Ronchi [of] [there] no, Wheezing nor there [is] 6. Heart : Iktus Cordis [of] [at] ICS IV mid clavicula Sinistra. [At] Auskultasi heard [by] single BJ I and single BJ II [do] not there are voice of additional heart 7. Abdomen : Form to level off. [At] percussion voice thympani, Noisy Auskultasi [of] intestine 12 X / minute. Palpasi [do] not there are abnormal mass, hepatomegali [of] [there] no, asites [of] [there] no, pain in bone depress [there] no 8. Genetalia : Clean [do] not there are blood, peaky [there] no, melena [of] [there] no
 turning white kehitaman, dry hurt, pus [of] [there] no, blood [of] [there] no. While hurt of heel of chromatic kemeraha
9. Ekstrimitas : Muscle Strength : 5 5
 4 5
 Oedema [of] [there] no. [At] ekstrimitas for attached [by] a left plaque on-hand, there are chafed hurt minimize [at] left ankle, dry hurt with diameter 1 cm and [there] no blood.
 There are right foot/feet back hurt and heel with dry hurt circumstance, [at] foot/feet b erwarna squeezing back [of] [at] periphery and turn white kehitaman [of] [at] its[his] middle. Hurt [of] [at] heel in the form of chafed meagrely the network nekrosis and blood.
 10. Inspection Neurologis
 Vomit [there] no, stiff [of] scruff [of] [there] no, is not confused, GCS 4 5 6 M. Supporter Inspection of[is date of 22 Februari 2005
 Laboratory : Complete Blood
 Hb : 11, 7 gram / dl
 pCV : 34
 Leucocyte : 14.900 / cm3
 LED : 113 - 117 / clock
 Evaluate hapusan blood ; Normochrome Normocitter
 Impressive sum up leucocyte : Mounting
 Impression sum up trombosite : Normal
 Faal Hemostasis " Trombosite 154.000 / cm3
 Chemical [of] Klinis " Blood Sugar fast : 165 mg / dl " Blood sugar 2 clock pp : 193 mg / dl
 Fat " Kolestrol : 215 mg / dl " Triglyceryda : 123 mg / dl " HDL Kolestrol : 20 mg / dl " LDL Kolestrol : 170 mg / dl
 Kidney function " BUN : 15,5 mg / dl " Ureum : 33,2 mg / dl " Creatine : 0,83 " Uric Acid : 9,6
 Faal Liver " SGOT : 18 " SGPT : 23
 Unlucky, 28 Februari 2005
 Nurse
lient tell hurt back of [his/its] right foot/feet felt [by] pain in bone [of] like ditusuk-tusuk, especially moment [in] moving
 Client show scale of [his/its] pain in bone 5
 DO :
 KU : Enough Awareness : CM
 RR : 20 X / minute Nadi : 88 X / minute
 Temperature : 37o C Tension : 140 / 90 mm Hg
 There are hurt back of right foot/feet and the right heel
 Hurt circumstance : white [of] kehitaman, pus [of] [there] no, blood [of] [there] no
 Hurt taken care of [by] 1 X / day with compress of betadin and closed [by] kassa
 DS :
 Client tell is not delicious eat and only finish ½ portion of [his/its] food
 DO :
 KU : Enough Awareness : CM
 Intake only ½ portion of food of Tooth of client a lot have the date of
 Client less take a fancy to vegetable
 Inspection Albumin : 2,51 gr / dl
 Queasy and vomit [there] no. [there] no
 Nadi : 88 X / minute RR : 20 X / minute
 Temperature : 37o C Tension : 140 / 90 mm Hg
 DO :
 Client tell hurt [in] [his/its] foot/feet initially only the small hurt, later;then extend
 DS : There are hurt back of right foot/feet and the right heel
 Hurt circumstance : white [of] kehitaman, pus [of] [there] no, blood [of] [there] no, wide [of] hurt 7 cm
 [At] heel of colour hurt of wide squeezing 2 cm there [is] a few/little blood, pus [of] [there] no
 Hurt taken care of with compress of betadine 1 X / day covered with [by] gauze
 DS
 Client tell [his/its] body is not hot and [his/its] hurt [is] felt [by] pain in bone
 DO
 KU : Whether Awareness : CM
 TTV
 Nadi : 88 X / minute RR : 20 X / minute
 Temperature : 37o C Tension : 140 / 90 mm Hg
DO :
 Client tell hurt [in] [his/its] foot/feet initially only the small hurt, later;then extend
 DS : There are right foot/feet back hurt and the right heel
 Hurt circumstance : white [of] kehitaman, pus [of] [there] no, blood [of] [there] no, wide [of] hurt 7 cm
 [At] wide squeezing hurt colour heel 2 cm there [is] a few/little blood, pus [of] [there] no
 Hurt taken care of with compress betadine 1 X / day covered with [by] gauze
 DS
 Client tell [his/its] body is not hot and [his/its] hurt [is] felt [by] pain in bone
 DO
 KU : Whether Awareness : CM
 TTV
 Nadi : 88 X / minute RR : 20 X / minute
 Temperature : 37o C Tension : 140 / 90 mm Hg
 Inspection Lab Leucocyte 14.900 / cm3
 Blood sugar fast 165 mg / dl
 GD 2 clock pp 195 mg / dl
 Hurt circumstance : white [of] kehitaman, pus [of] [there] no, blood [of] [there] no, wide [of] hurt 7 cm
 [At] wide squeezing hurt colour heel 2 cm there [is] a few/little blood, pus [of] [there] no
 Hurt taken care of with compress betadine 1 X / day covered with [by] gauze
 DS :
 Client tell if very rare at home have the athletics
 Client tell to dive [in] RS only berbaruing, because hurt will increase pain in bone [of] if/when moved
 DO :
 Client [is] worker pensioner immunize
 Client have never olahraga
 Pain in bone [is]
 Accomplishment Nutrisi less than the requirement
 husk Integrity damage
 High risk [of] infection spreading
 Lack of knowledge to important [of] athletic nya for the right DEUTSCHMARK Diskontinuitas network sekunder foot/feet back hurt existence patient
 anorexia
 Hurt existence [of] [at] right foot/feet back
 Loss of body primary defender
 Lack of Information which got
Pain in bone [is] relate to right Diskontinuitas network sekunder foot/feet back hurt existence
 accomplishment Nutrisi less than the requirement relate to Anorexia
 husk Integrity Damage relate to right foot/feet back hurt existence
 High risk [of] infection spreading relate to the loss of holding up [of] primary body
 Lack of knowledge to important [of] athletic nya for the DEUTSCHMARK patient relate to the Lack of information which got

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