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  • Follow Up DPH 1-2

    Diunggah oleh

    Sausan Hana Maharani
    17 tayangan1 halaman
    The patient presented with restlessness, slurred speech, and left-sided facial droop. On examination, the patient had elevated blood pressure, irregular pulse, and signs of upper motor neuron involvement on the left side. An assessment found the patient had slight left hemiparesis and facial nerve palsy due to a recurrent stroke causing intracerebral hemorrhage in the subcortex. The treatment plan included head elevation, IV fluids, medications to control blood pressure and prevent stomach ulcers, and citicoline to improve neurological recovery. The patient was admitted for monitoring of vital signs.

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    Judul Asli

    Follow up DPH 1-2

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    The patient presented with restlessness, slurred speech, and left-sided facial droop. On examination, the patient had elevated blood pressure, irregular pulse, and signs of upper motor neuron involvement on the left side. An assessment found the patient had slight left hemiparesis and facial nerve palsy due to a recurrent stroke causing intracerebral hemorrhage in the subcortex. The treatment plan included head elevation, IV fluids, medications to control blood pressure and prevent stomach ulcers, and citicoline to improve neurological recovery. The patient was admitted for monitoring of vital signs.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    17 tayangan1 halaman

    Follow Up DPH 1-2

    Diunggah oleh

    Sausan Hana Maharani
    The patient presented with restlessness, slurred speech, and left-sided facial droop. On examination, the patient had elevated blood pressure, irregular pulse, and signs of upper motor neuron involvement on the left side. An assessment found the patient had slight left hemiparesis and facial nerve palsy due to a recurrent stroke causing intracerebral hemorrhage in the subcortex. The treatment plan included head elevation, IV fluids, medications to control blood pressure and prevent stomach ulcers, and citicoline to improve neurological recovery. The patient was admitted for monitoring of vital signs.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 1

    Tanggal

    Subjektive
    Subjective
    Objective

    Objective

    18 11
    17
    112016
    2016(DPH
    ( DPH1)
    2)
    Gelisah
    GCS : E4V5M6
    Tensi: 150/100
    220/160 mmHg
    Nadi: 86
    90 x/menit, reguler
    RR: 20x/menit
    Suhu: 36,7C
    36,6C
    Vas: 0
    Fungsi luhur : disartria
    Meningeal sign : tidak ada
    Nn. craniales:
    N.II, III : pupil isokor (3 mm/3mm), refleks cahaya ( +/+)
    N.III, IV, VI : dalam batas normal
    N.V : refleks kornea (+/+)
    N. VII, XII: parese sinistra UMN
    Motorik:
    K 5/5/5 4+/4+/4
    T n
    n
    K 5/5/5
    T n
    n
    +
    5/5/5 4+/4+/4
    n
    n
    5/5/5
    n
    n
    +
    R
    F

    Assessmen
    Assessmen
    t
    t
    Planning

    Planning

    +2
    +2

    +3
    +3

    +2

    +2

    R
    P

    Fungsi sensorik : sulit dievaluasi


    Fungsi otonom : dalam batas normal
    Fungsi koordinasi: sulit dievaluasi
    K: Slight hemiparese (S), parese N. VII, XII (S) UMN, disartria
    T: subcortex (D)
    E: Recurrent Stroke et causa ICH
    Terapi:
    Head up 30
    Infus NaCl 0,9% 20 tpm
    Inj. Ranitidin 50mg/12 jam i.v
    Inj. Citicolin 250mg/24 jam i.v
    Inj. Perdipin 10mg dalam NS 50cc dengan kecepatan 7,5cc/jam
    Amlodipin 10mg/ 24 jam p.o
    Candesartan 16mg/24 jam p.o
    Plan:
    Observasi KUVS
    KUVS, target TDS 160 atau MAP 110

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