NAME : ANNIS OKTARIANI

NIM : P3.73.20.3.15.006

CLASS : 2 REGULER C

Resume

On Tuesday Tn. Bagas 46th years old treated in the disease in complaints of injury does
not heal. Mr. bagas looks weak and complain of headaches. The patient has a history of DM. the
physical examination seen a large enough and in the wounds are fresh, blood glucose levels,
4.000 mg/dL, blood pressure 140/80 mmHg, the frequency pulse 80x/minutes, the frequency of
breath 20x/minutes, the temperature 38 C.

A. Assement
Check-in date : 9th Mey 2017
Room : Cempaka Atas / Room 5
Diagnose : Diabetes Melitus

1. The Identity of patients

Patients Name : Mr. Bagas Hermanto
Age : 46th years old
Marital Status : Married
Job : PNS
Last Education : S1
Tribe : Java
Source of cost : BPJS
Address : Jl. Persahabatan Timur 3 No.15 RT01/05 Jakarta Timur

Date of Hospital Admission : 9th Mey 2017

Wifes Name : Sulastri
Age : 40th years old
Job : Wife House
Religion : Islam
Last Education : SMA
Tribe : Padang
Address : Jl. Persahabatan Timur 3 No.15 RT01/05 Jakarta Timur
B. Data analysis

1. Subjective Data
Patient complained of injuries does not heal.
Patient complained of headaches
Patient says it him a history of diabetes Mellitus

2. Objective Data
Patient looks weak.
Its fairly wide color of red and fresh.
Blood glucose levels, 4.000 mg/dL.
blood pressure 140/80 mmHg
The frequency pulse 80x/minutes
The frequency of breath 20x/minutes
The temperature 38 C.

C. Diagnosis

1. The disturbance of a sense of comfort the pain associated with a gangrene

2. This is a disorder of the network in touch with the gangrene in ekstrimitas

D. Intervention

1. Diagnosis 1 :

Review of the wounds and the healing process

Review level, frequency, and the pain experienced by patients.
Teach the technique distraksi and relaxation.
Set the position of the patient as comfortable as ppossible to patient
Do the massage and compress the wound with BWC when treated the wound.
Collaboration with the doctor for the provision of analgesics

2. Diagnosis 2 :

Review the wounds and the healing process

Treat the wound with good and true techniques aseptic
Clean the wounds patients doing a sterile with Nacl and Debridement
Control is no sign of infection in the injured
Collaborartion with the provision of insulin
 Review the blood sugar to antibiotics