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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