Selasa, 23 Agustus 2011

PENGKAJIAN FISIK data siluman


PENGKAJIAN FISIK
- Keadaan umum                         : Composmentis.
                                                   E : 4
                                                   M: 6
                                                   V            : 4

- TTV                                         :
                                                   TD          : 130/ 90 mmhg
                                                   S             : 37 c
                                                   HR          : 92 x / mnt
                                                   Rr           : 16 x / mnt
- Kepala ( rambut )                      : Distribusi merata, kuat, tak ada lesi, beruban
                                                      dan kotor.
- Mata                                         : Simetris, pupil isokor, sklera tdk icterik,
                                                      conjungtiva tdk anemis.
- Hidung                                      : Fungsi penciuman Baik, tdk ada pembesaran
                                                      polip.
- Mulut                                        : Tidak ada stomatitis, lidah agak kotor , ada
                                                      carries, mukosa bibir kering.
- Telinga                                      : Simetris, tdk ada lesi, tdk ada penumpukan
                                                      serumen.
- Leher                                        : Tdk ada lesi, gland tiroid teraba, tdk ada           
                                                      peningkatan JVP.
- Dada             - Paru – paru       I    : Simetris
                                                   Pa : Tidak ada nyeri tekan.
                                                   Pe :  Sonor
                                                   A              :  Bronkovesikuler
                        - Jantung             I    :  Ictus cordis tak tampak
                                                   Pa  :  Ictus cordis teraba  
                                       Pe  :  Pekak
                                       A   :  Ireguler
                  - Abdomen                                  I    :  Agak buncit, luka terbuka reg. V
                                                                     A   :  Peristaltik 8 x / mnt
                                                                     Pa  :  Ada nyeri tekan pada reg. V
                                                                     Pe  :  pekak
                  - Extremitas ( dex, sin )                : Atas tak dapat bergerak bebas, tak ada lesi,
                                                                        terpasang infus. Bawah tak ada lesi,
                                                                        bergerak bebas.
                  - Genetalia                                   : terpasang DC, tak ada lesi.
                  - Anus                                         : Bersih , tak ada hemoroid.



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