Tgl Subyektif Obyektif Assasment Plan18/112010

BAK(-),flatus(+),BAB(+),riwayat post Op Open proatatektomi 4th yll

KU:sedang,CMSt.lokalis AbdomenI:flat,Suprapubik menonjolA:peristaltik +Per:TympaniPal:NT(+)suprapubik

Retensi urine post open postatektomi

-diet bebas TKTP-Infus RL 16 tpm-Inj Cefotaxime 2x1gr-Inj Ranitidin 2x1amp-Inj Ketorolac 3x10mg-pro pasang DC di OK 18/11/10metal kateterurine keluar

19/112010

BAK(-),flatus(+),BAB(+),riwayat post Op Open proatatektomi 4th yll

KU:sedang,CMSt.lokalis AbdomenI:flat,Suprapubik tenangA:peristaltik +Per:TympaniPal:NT(-)suprapubik

Retensi urine post open postatektomi

-diet bebas TKTP-Infus RL 16 tpm-Inj Cefotaxime 2x1gr-Inj Ranitidin 2x1amp-Inj Ketorolac 3x10mg-pro Rekanalisasi ulang di OK 20/11/10-Inj Kalnex 3x500mg (Prn)

20/112010

BAK(-),flatus(+),BAB(+),riwayat post Op Open proatatektomi 4th yll

KU:sedang,CMSt.lokalis AbdomenI:flat,Suprapubik menonjolA:peristaltik +Per:TympaniPal:NT(+)suprapubik

Striktur Uretra post open postatektomi

-Puasa (+)-IC (+)Co.Anastesi (+)-Infus RL 16 tpm-Inj Cefotaxime 2x1gr-Inj Ranitidin 2x1amp-Inj Ketorolac 3x10mg-Inj Kalnex 3x500mg (Prn)-pro pasang DC di OK 20/11/10 dgn GA-pro close cystostomi

22/112010

BAK(+)selang cystostomi,flatus(+),BAB(+)

KU:sedang,CMSt.lokalis AbdomenI:flat,Suprapubik tenang,luka tertutup kassa,drain(+) Produk +- 60 ccA:peristaltik +Per:TympaniPal:NT(+)suprapubik

Striktur Uretra post open postatektomi post cystostomi H1

-diet bebas TKTP-Infus RL 16 tpm-Inj Cefotaxime 2x1gr-Inj Ranitidin 2x1amp-Inj Ketorolac 3x10mg-Inj Kalnex 3x500mg (Prn)-pro Sectio Alta 23/11/10

23/112010

Lemas(+),BAK(+),flatus(+),BAB(+)

KU:sedang,CMSt.lokalis AbdomenI: flat,Suprapubik tenang,luka tertutup kassa,drain(+) Produk +- 70 ccA:peristaltik +Per:TympaniPal:NT(+)suprapubik

Striktur Uretra post open postatektomi post cystostomi H2

-Puasa (+)-IC (+)Co.Anastesi (+)-Infus RL 16 tpm-Inj Cefotaxime 2x1gr-Inj Ranitidin 2x1amp-Inj Ketorolac 3x10mg-Inj Kalnex 3x500mg (Prn)-pro sectio alta 23/11/10

24/112010

BAK(+),flatus(+),BAB(-) KU:sedang,CMSt.lokalis AbdomenI: flat,Suprapubik tenang, luka SP tertutup

Striktur Uretra post open postatektomi post Sectio

-Diet bebas TKTP-Infus RL 16 tpm-Inj Cefotaxime 2x1gr-Inj Ranitidin 2x1amp

kassa,rembes(-),MUE terpasang kateter Produk serous +- 100 ccA:peristaltik +Per:TympaniPal:NT(+)suprapubik

Alta H1 -Inj Ketorolac 3x10mg-pertahankan DC sampai 14 hari

25/112010

BAK(+),flatus(+),BAB(+)

KU:sedang,CMSt.lokalis AbdomenI: flat,Suprapubik tenang, luka SP tertutup kassa,rembes(-),MUE terpasang kateter Produk kemerahan +- 120 ccA:peristaltik +Per:TympaniPal:NT(+)suprapubik

Striktur Uretra post open postatektomi post Sectio Alta H2

-Diet bebas TKTP-Infus RL 16 tpm-Inj Cefotaxime 2x1gr-Inj Ranitidin 2x1amp-Inj Ketorolac 3x10mg-pertahankan DC sampai 14 hari

24/112010

BAK(+),flatus(+),BAB(-),pusing(-)

KU:sedang,CMSt.lokalis AbdomenI: flat,Suprapubik tenang,luka SP tertutup kassa,rembes(-),MUE terpasang kateter Produk serous +- 80 ccA:peristaltik +Per:TympaniPal:NT(+)suprapubik

Striktur Uretra post open postatektomi post Sectio Alta H3

-Diet bebas TKTP-Infus RL 16 tpm-Inj Cefotaxime 2x1gr-Inj Ranitidin 2x1amp-Inj Ketorolac 3x10mg-pertahankan DC sampai 14 hariBLPL-kontrol poli bedah 3 hari pasca pulang (DC terpasang)-Amoxan3x500mg-As.Mefenamat3x500mg