ASSESSMENT
e. Family health history
Disease in the suffering / still in pain :
VII. HEALTH HISTORY TODAY
1. Ksehatan current: Patients in objec nervous, weak and cranky
2. Physical Examination: Date: 10 August 2011 at: 14.00wib
Vital signs: Respiratory: 30 x / i
: Pulse: 120 x / i
: Temp: 37.6 ° C
3. Provkatif / valiatif: stoma / colostomy actions
4. Qualitas
Scale: 6 (medium)
5. Region / area: descending colon area, the width of stoma ± 3 cm
6. Severaty: pain lasts for approximately 10 minutes
7. Time / time: when children are moving
VIII. HEAD TO TOE EXAMINATION
1. Hair and scalp
His hair is clean and cover the entire scalp. Scalp is clean
2. Head and neck
a. Head
Round head shape and the posterior and anterior pontanel has closed. Suture is fused.
b. Neck
Patient's neck shape is symmetrical and no pembengkakakan. Head can move freely and there is no pain or resistance. Trachea was in the midline and there is no swelling or tenderness. Normal jugular venous pressure.
c. Ear
In the ear auricle no lesions or inflammation. Wax was just within normal limits. There is no inflammation of the ear and auditory function that can be turned to good patient when atrial name on the call.
d. Eye
Negative visual function can not see objects within a 10-50cm.Tidak there anemis the conjunctiva and the sclera no ikhterik. Iris light reflex in normal and abnormal keadaa.
e. Face nose and mouth
X. Pattern Body hygiene
Children washed 2 x / day by the mother, the child can not brush my teeth because not having teeth and wash your hair done 2 x / day stiap children bathed by his mother. Cut nails done 1 x / week.
XI. Parental knowledge about health
a. Food for kids
Give him food on to his son was breastfed
b. The causes of disease
Mom said that her illness is a disease due to congenital birth
c. Home Environment
Mom says adalh healthy environment clean and tidy
d. Examination at this time
Conscious child (compos mentis), weak, cranky and restless.
pols : 120 x / min
Respiratory : 30 x / min
Temperature : 37.6 ° C
XI. Diagnostic Examination / Support
I. Biodata
Name : By. S
Age : 10 days
Gender : Female
Religion : Islam
Ethnic groups : Java-Indonesia
Address : Lae Simolap, Sumbul Greetings
Dates : August 6, 2011
Rooms : RB2 A Room III
Operation Date: August 8, 2011
II. PARENTS IDENTITASS
1. Father
Name : Mr.. Wantu
Age : 25 years
Occupation : Farmer
Tribal Nation : Java-Indonesia
Address : Lae simolat
Education : Elementary
Religion : Islam
2. Mrs.
Name : Ny. Suminem
Age : 45 Years
Occupation : Farmer
Tribal Nation : Java-Indonesia
Address : Lae simolat, Sumbul Greetings
Education : Elementary
Religion : Islam
III. BIRTH HISTORY
After the second pregnancy the mother gave birth to a daughter who is now 5 days old and was born spontaneously with the help of midwives and traditional birth attendants but has a disorder that is when the baby is born has no anus.
IV. REASON IN HOSPITALS / MAIN COMPLAINT
Mother and her family told since birth have no anus and when urination seem feces mixed with urine.
V. PAST HEALTH HISTORY
a. Medical history before birth
During the unborn child's mother has never had any illness and never do a pregnancy.
b. Birth history
Children are born normally assisted by midwives but kongenita disease (atresia ani).
c. History of neonatal
Apgar score : it can not be studied
BB Born : 3 kg
PB birth : 46 cm
d. Medical history
Name : By. S
Age : 10 days
Gender : Female
Religion : Islam
Ethnic groups : Java-Indonesia
Address : Lae Simolap, Sumbul Greetings
Dates : August 6, 2011
Rooms : RB2 A Room III
Operation Date: August 8, 2011
II. PARENTS IDENTITASS
1. Father
Name : Mr.. Wantu
Age : 25 years
Occupation : Farmer
Tribal Nation : Java-Indonesia
Address : Lae simolat
Education : Elementary
Religion : Islam
2. Mrs.
Name : Ny. Suminem
Age : 45 Years
Occupation : Farmer
Tribal Nation : Java-Indonesia
Address : Lae simolat, Sumbul Greetings
Education : Elementary
Religion : Islam
III. BIRTH HISTORY
After the second pregnancy the mother gave birth to a daughter who is now 5 days old and was born spontaneously with the help of midwives and traditional birth attendants but has a disorder that is when the baby is born has no anus.
IV. REASON IN HOSPITALS / MAIN COMPLAINT
Mother and her family told since birth have no anus and when urination seem feces mixed with urine.
V. PAST HEALTH HISTORY
a. Medical history before birth
During the unborn child's mother has never had any illness and never do a pregnancy.
b. Birth history
Children are born normally assisted by midwives but kongenita disease (atresia ani).
c. History of neonatal
Apgar score : it can not be studied
BB Born : 3 kg
PB birth : 46 cm
d. Medical history
- congenital defects: Children have a congenital defect that has no anus
- Diseases in natural: Babies suffering from congenital disease that is not having the anal canal.
- Never in care: never in care
- Lama in care: never
- Drug obtan: family not remember anymore
- Allergies: No history of allergy in the patient's natural
e. Family health history
Disease in the suffering / still in pain :
\ family member having an infectious disease Hepatitis is in the suffering grandfather patient.
Infectious diseases: There, hepatitis
Infectious diseases: There, hepatitis
Hereditary disease : keluara patients do not have hereditary diseases
f. Genogram
patient was the second of two brothers, a father of three children with her first child and the mother the second of three brothersFather's family mother's family
VI. IMMUNIZATION HISTORY
Patients do not remember the types of immunizations given to children
a. History of growth and development
f. Genogram
patient was the second of two brothers, a father of three children with her first child and the mother the second of three brothersFather's family mother's family
VI. IMMUNIZATION HISTORY
Patients do not remember the types of immunizations given to children
a. History of growth and development
- Physical growth: BB: 3 kg PB: 46 cm
- Gross motor development: infants have not been able to stomach and raised his head.
- Fine motor development: the child has been able to smile when baby's cheek.
- Language development: Children can only cry
- Social development: Children are not Able to recognize the voice of the closest and mother calling her son as "mang"
- Cognitive development: can not yet studied
VII. HEALTH HISTORY TODAY
1. Ksehatan current: Patients in objec nervous, weak and cranky
2. Physical Examination: Date: 10 August 2011 at: 14.00wib
Vital signs: Respiratory: 30 x / i
: Pulse: 120 x / i
: Temp: 37.6 ° C
3. Provkatif / valiatif: stoma / colostomy actions
4. Qualitas
Scale: 6 (medium)
5. Region / area: descending colon area, the width of stoma ± 3 cm
6. Severaty: pain lasts for approximately 10 minutes
7. Time / time: when children are moving
VIII. HEAD TO TOE EXAMINATION
1. Hair and scalp
His hair is clean and cover the entire scalp. Scalp is clean
2. Head and neck
a. Head
Round head shape and the posterior and anterior pontanel has closed. Suture is fused.
b. Neck
Patient's neck shape is symmetrical and no pembengkakakan. Head can move freely and there is no pain or resistance. Trachea was in the midline and there is no swelling or tenderness. Normal jugular venous pressure.
c. Ear
In the ear auricle no lesions or inflammation. Wax was just within normal limits. There is no inflammation of the ear and auditory function that can be turned to good patient when atrial name on the call.
d. Eye
Negative visual function can not see objects within a 10-50cm.Tidak there anemis the conjunctiva and the sclera no ikhterik. Iris light reflex in normal and abnormal keadaa.
e. Face nose and mouth
- Roman face: a child's face looked glum as she felt ill
- Nose: the nose area no pain. Function penciumanya can not yet be assessed, moist nasal mucosa, no bleeding and inflammation and also no polyps.
- Mouth: mucous membranes moist lips, tongue, patients are not no abnormalities and no swelling of the tonsils, red gums, and children do not have teeth, there is no difficulty in swallowing.
f. Chest and lungs
1. Lungs: symmetrical and thoracic breathing kind torako abdominal, normal breathing pattern is eupnea. On
when not aa palpation tenderness and expansion symmetrical lung. Premitus Traktil normal. At the time of
percussion sounds in normal and pulmonary boundaries in Under normal circumstances when in
1. Lungs: symmetrical and thoracic breathing kind torako abdominal, normal breathing pattern is eupnea. On
when not aa palpation tenderness and expansion symmetrical lung. Premitus Traktil normal. At the time of
percussion sounds in normal and pulmonary boundaries in Under normal circumstances when in
auscultation sounds vesicular breathing and no cough.
2. Cardiovascular System
Cardiac: heart size was not in the review, heart sounds BJ BJ I & II on the loop- dup. regular heart rhythm.
System and peripheral radial pulse vaskulernya same.
g. Abdomen
2. Cardiovascular System
Cardiac: heart size was not in the review, heart sounds BJ BJ I & II on the loop- dup. regular heart rhythm.
System and peripheral radial pulse vaskulernya same.
g. Abdomen
- Insfeksi: at the time of inspection Kuntur abdomen in an average and no ascites. Masses and tumors, striae and umbilicus in good condition and there is no inflammation. and the stoma on the abdomen on the left.
- Percussion: sat in the abdomen timpani percussion sounds.
- Palpation: when there is tenderness on palpation because the former operation.
- Auscultation: at the time of increased bowel sounds in auscultation that is 24 x / i.
h. Reproductive System
The patient was a woman, breasts and nipples have not looked, and looked aerolanya brownish black. No mass atu About a tumor in the reproductive parts and labiya, her clitoris is in good condition, and no inflammation or redness. Urethra and vagina in keadaa norm, no red and no edema.
i. Extremity
Upper limb: muscle strength against resistance 4 is able to and move freely, infusion plugged in hand left.
Lower limb: muscle strength 4, which can resist resistance and move freely, a little weak. No abnormalities and fractures, paralysis.
IX. PATTERN OF BEHAVIOR TODAY
A. Nutrition
1. Before entering the hospital
irregular eating patterns of patients because only a child breastfeeding, breastfeeding in doing so giving every kid crying irregular.
2. After entry Hospitals
irregular eating patterns of patients because makananya only breast milk and given order to each time a child cries and wants to drink less milk.
B. Elimination
1. Before entering the hospital
CHAPTER: Mom said she did not know how many times the child
CHAPTER in one day because his son did not have anus.
BAK: frequency of 6-7 times / day
2. After entry Hospitals
CHAPTER: kolostomy installed and replaced colostomy 2 x / day
BAK: 400 cc / day.
C. The pattern breaks
1. Before entering the hospital
Before entering the Hospital children always nap at 11.00 up to 14:00 pm. To sleep the night at 20.00 up to 06:00 pm.
2. After entering the hospital.
Hospital after entering the child naps at 10.00 up to 14:00 pm and in the evening at 20.00 tiurnya up to 06:00 pm. For sleep problems children often disrupted due to giving injections and pain that sometimes arise.
D. The pattern of activity
The patient was a woman, breasts and nipples have not looked, and looked aerolanya brownish black. No mass atu About a tumor in the reproductive parts and labiya, her clitoris is in good condition, and no inflammation or redness. Urethra and vagina in keadaa norm, no red and no edema.
i. Extremity
Upper limb: muscle strength against resistance 4 is able to and move freely, infusion plugged in hand left.
Lower limb: muscle strength 4, which can resist resistance and move freely, a little weak. No abnormalities and fractures, paralysis.
IX. PATTERN OF BEHAVIOR TODAY
A. Nutrition
1. Before entering the hospital
irregular eating patterns of patients because only a child breastfeeding, breastfeeding in doing so giving every kid crying irregular.
2. After entry Hospitals
irregular eating patterns of patients because makananya only breast milk and given order to each time a child cries and wants to drink less milk.
B. Elimination
1. Before entering the hospital
CHAPTER: Mom said she did not know how many times the child
CHAPTER in one day because his son did not have anus.
BAK: frequency of 6-7 times / day
2. After entry Hospitals
CHAPTER: kolostomy installed and replaced colostomy 2 x / day
BAK: 400 cc / day.
C. The pattern breaks
1. Before entering the hospital
Before entering the Hospital children always nap at 11.00 up to 14:00 pm. To sleep the night at 20.00 up to 06:00 pm.
2. After entering the hospital.
Hospital after entering the child naps at 10.00 up to 14:00 pm and in the evening at 20.00 tiurnya up to 06:00 pm. For sleep problems children often disrupted due to giving injections and pain that sometimes arise.
D. The pattern of activity
- Play: children are not able to play
- School: children not attending school
X. Pattern Body hygiene
Children washed 2 x / day by the mother, the child can not brush my teeth because not having teeth and wash your hair done 2 x / day stiap children bathed by his mother. Cut nails done 1 x / week.
XI. Parental knowledge about health
a. Food for kids
Give him food on to his son was breastfed
b. The causes of disease
Mom said that her illness is a disease due to congenital birth
c. Home Environment
Mom says adalh healthy environment clean and tidy
d. Examination at this time
Conscious child (compos mentis), weak, cranky and restless.
pols : 120 x / min
Respiratory : 30 x / min
Temperature : 37.6 ° C
XI. Diagnostic Examination / Support
No | Date of Examination | type of inspection | result |
1 | 30-07-2011 | Thoraks | · Heart & Lung within normal limits · Thymus hyperplasia |
2 | 30-07-2011 | Colon | Recto vaginal fistel |
3 | 02-08-2011 | Blood Sugar Levels | 85.000 mg/dL |
4 | 02-08-2011 | Urine | Ureum : 12,00 mg/dL Kreatinin : 0,27 mg/dL Asam urat : 2,5 mg/dL |
5 | 02-08-2011 | CBC | HB : 12,10 gr % Eritrosit : 5,47 .106/mm3 Leukosit : 15,21.103/mm3 Trombosit : 38,6 .103/mm3 Hematokrit: 38,40 % MCV : 70.20 fl McHc : 31,50 gr % PCT : 0,35 % PDW : 9,5 fl count type Neutrofil :32,50 % Limfosit : 55,20 % Monosit : 6,90 % Basofil : 5,20 % Eusofil : 0,200 % Neutrofil absolute : 3,22. 103/₰L Limfosit absolute : 5,47. 103/₰L Monosit absolute : 0,68. 103/₰L Basofil absolute : 0,02. 103/₰L Eusofil absolute : 0,52.103/₰L |
XII. Therapy
IVFD 0.225% NaCl + 0.5%; 28 GTT / I micro
Injection: Novalgin 100mg/8jam/IV
Tramadol 20mg/8jam/IV
Cefotaxime 100mg/12jam/IV
Diet: breast milk
IVFD 0.225% NaCl + 0.5%; 28 GTT / I micro
Injection: Novalgin 100mg/8jam/IV
Tramadol 20mg/8jam/IV
Cefotaxime 100mg/12jam/IV
Diet: breast milk
