14

HARI PERAWATAN
EVALUASI 1 2 3 4 5 6
13/04/17 14/04/17 15/04/17 16/04/17 17/04/17 18/04/17
Panas - - - - - -
S Nyeri kaki + + + + < <
Nyeri sendi + + + < < -
Luka basah + + + + + +

TD (mmHg) 100/70 110/80 110/70 100/70 110/80 100/80

O N (kali/menit) 82 80 78 78 78 74
RR (kali/menit) 24 24 22 20 20 22
T (0C) 37,8 37,5 36,8 36,5 36,1 36
GDS 435 380 457 332 401 384
Ulkus diabetikum grade III Reg. Pedis Dextra ec Diabetes Mellitus type II
A
Uncontrolled
IVFD NaCl 0.9% gtt XX/menit + + + + - -
Inj. Rapid Insulin 3 x IU - - - - 15 iu 15 iu
Inj. Ceftriaxon 2x1 gr + + + + + +
Inj. Metronidazole 3x500 mg + + + + + +
Pletaal 2x50 mg tab - + + + + +
Lansoprazol 1x1 caps + + + + + +
P
Ibuprofen 2x200 mg (k/p) - - - - - -
Paracetamol 3x500 mg (k/p) - - - - - -
Neurodex 1x1 tab. + + + + + +
GV 2x1 (nacl +2 amp.genta)
Rawat gangren pagi & sore - + + + + +
Diet DM + + + + + +

HARI PERAWATAN
EVALUASI 7 8 9 10 11 12
19/04/17 20/04/17 21/04/17 21/04/17 22/04/17 23/04/17
Panas - - - - - -
S Nyeri kaki + + + + < <
Nyeri sendi + + + < < -
Luka basah + + + + + +

TD (mmHg) 100/70 110/80 110/70 100/70 110/80 110/80

O N (kali/menit) 82 80 78 78 78 74
RR (kali/menit) 24 24 22 20 20 22
T (0C) 37,8 37,5 36,8 36,5 36,1 36
GDS 350 261 285 268 296 235
Ulkus diabetikum grade III Reg. Pedis Dextra ec Diabetes Mellitus type II
A
Uncontrolled
IVFD NaCl 0.9% gtt XX/menit - - - - - -
Inj. Rapid Insulin 3 x IU 15 iu 15 iu 15 iu 17 iu 17 iu 18 iu
P Inj. Ceftriaxon 2x1 gr + + + + + +
Inj. Metronidazole 3x500 mg + + + + + +
Pletaal 2x50 mg tab + + + + + +
Lansoprazol 1x1 caps + + + + + +
 15

Ibuprofen 2x200 mg (k/p) + + + + + +

Paracetamol 3x500 mg (k/p) - - - - - -
Neurodex 1x1 tab. - - - - - -
GV 2x1 (nacl +2 amp.genta) + - + - + -
Rawat gangren pagi & sore + + + + + +
Diet DM + + + + + +
HARI PERAWATAN
EVALUASI 13 14 16 20 24 28
1/5/17 2/5/17 5/5/17 9/5/17 10//5/17 12/5/17
Panas - - - - - -
S Nyeri kaki + + + + < <
Nyeri sendi + + + < < -
Luka basah + + + + + +

TD (mmHg) 120/70 120/80 120/70 120/70 120/80 120/80

O N (kali/menit) 82 80 78 78 78 74
RR (kali/menit) 24 24 22 20 20 22
T (0C) 37,8 37,5 36,8 36,5 36,1 36
GDS 233 218 214 212 277 183
Ulkus diabetikum grade III Reg. Pedis Dextra ec Diabetes Mellitus type II
A
Uncontrolled
IVFD NaCl 0.9% gtt XX/menit + + + + + -
Inj. Rapid Insulin 3 x IU 18 iu 20 iu 20 iu 22 iu 22 iu 22 iu
Inj. Ceftriaxon 2x1 gr + + + + + STOP
Inj. Metronidazole 3x500 mg + - - - - -
Pletaal 2x50 mg tab + + + + + +
Lansoprazol 1x1 caps + + + + + +
P Ibuprofen 2x200 mg (k/p) + + + + + STOP
Paracetamol 3x500 mg (k/p) + + + + - STOP
Neurodex 1x1 tab. - - - + + +
GV 2x1 (nacl +2 amp.genta) - - - + + +
Rawat gangren pagi & sore + - + - + +
Diet DM + + + + + +

Follow up
Tabel 2. Follow up tanggal 13 April 2017 12 Mei 2017