Professional Documents
Culture Documents
subect
object
assesment
planning
20.00
Headhache (+), epigastric pain (+), blur vision (-). Abdominal pain (+) rare
General condition : well BP : 160/100 mmHg Pulse : 84x/mnt RR : 22x/mnt Temp : 37. 8 C UP : 60 cc/hr FHR : 148x/mnt UC : 2x/10-20
G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge
20.30
Headhache (+), epigastric pain (+), blur vision (-). Abdominal pain (+) rare
General condition : well BP : 160/100 mmHg Pulse : 88x/mnt RR : 20x/mnt Temp : 37. 8 C FHR : 168x/mnt UC : 2x/10-20
General condition : well BP : 160/100 mmHg Pulse : 80x/mnt RR : 22x/ mnt Temp : 37.5 C UP : 45 cc/hr FHR : 164x/mnt UC : 2x/10-20
G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge+fetal tachicardia
21.00
Headhache (+), epigastric pain (+), blur vision (-). Abdominal pain (+) rare
G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge+fetal tachicardia
-Evaluate mother and fetal well being -Obs. VS -Report to superviser for planning VE, -Advis : evaluate again and report again
22.00
General condition : well BP : 140/100 mmHg Pulse : 80x/mnt FHR : 150x/mnt UC : 2x/10-20
G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge
-Evaluate was done but not improve so report to superviser again and propose SC Proposed agreed
Time 22.30
subect
object General condition : well BP : 150/100 mmHg Pulse : 80x/mn Tax : 37.4 C UC : 2x/10-20
assesment
planning -Prepare SC
G1P0A0L0 A/S/L/IU with head presentation + negleted 2 nd stage of labor + eclampsia + history of watery vaginal discharge
23.00
Baby was born with head presentation and coiled placenta 2x : Male, 3200 gr, length 49 cm, AS 7-9, anus (+) Placenta complete, weight not measure, AM green thick, little amount.
00.30
-Evaluate VS of mother -Evaluate Subjective complain -Evaluate wound operation -Evaluate UC -Educate mother to breast feeding
-Evaluate mother and fetal well being -Obs. VS
06.00
1 day post SC
Time
subect
VT : CD 4 cm, eff 50 %, AM (+), head palpable, H2+, small organ and umbilical cord wasnt palpable History of obstetry: 1. this Lab : Proteinuria (+)3 Therapy in kr taliwang PHC : Infus RL Nifedipine 10 mg sublingual In VK : Blur vision (+), epigastric pain (-), headhache (+)
object Pelvic evaluate : Spina ischiadica not prominent Os coxigeus mobile Distansia tuberum >90 Hb : 15.0 gr% Leukosit : 11600 Hematorit : 36.9 trombosit :235000 HbSAg (-) Proteinuria : (+)2
assesment
planning
, 12.30 Subjectiv complain (+) General condition : well BP : 150/100 mmHg Pulse : 80x/mnt RR : 18x/ mnt Temp : 36,4 C UC : 3x/10-30 FHR : 140x/mnt
G1P0A0L1 P/S/L/IU with HEAD presentation +prolong active phase 1 stage labor+ PEB
Time 1430
object General condition : well BP : 140/110 mmHg Pulse : 84x/mnt Temp : 36,7 C UP : 70 cc/hr FHR : 128x/mnt UC : 3x/10-35
BP : 160/100 mmHg Pulse : 76x/mnt FHR : 130x/mnt UC : 3x/10-35 VT : CD 5 cm, eff 50 %, AM (+), head palpable, H2+, small organ and umbilical cord wasnt palpable
assesment G1P0A0L1 P/S/L/IU with HEAD presentation + prolong active phase 1 stage labor+ PEB
16.00
G1P0A0L1 P/S/L/IU with HEAD presentation + prolong active phase 1 stage labor+ PEB
-Report to supervisor -Proposed amniotomy, propose agree -Amniotic fluid : 30 cc, clear
16.30
General condition : well BP : 140/110 mmHg Pulse : 84x/mnt Temp : 36,7 C UC : 3x/10-35 FHR : 118x/mnt
G1P0A0L1 P/S/L/IU with HEAD presentation + prolong active phase 1 stage labor+ PEB
-Evaluate mother and fetal well being -Obs. VS -O2 5 lpm -Resusitasi RL : D5% 2:1 max drop -Left lateral position -CTG -Bolus MgSo4 2 gr IV
17.00
Convulsi 3 minute
G1P0A0L1 P/S/L/IU with HEAD presentation + prolong active phase 1 stage labor+ eclampsia
Time
subect
object
assesment
planning
17.45
18.10
Baby was born with vacuum extraction, male, AS : 3-5 , W : 3500 gr, caput + baby sent to NICU -Placenta was born, completed, spontaneously episiotomi
-Evaluate mother -Obs. VS
20.10
General condition : well BP: 100/60 mmHg P: 88x /m RR:18x/m T : 36,9C UC : good UFH = 2 finger below umbilical
4 stage of labor
07.00
BP : 100/60 mmHg Pulse : 80x/mnt Rr : 16 x/mnt T: 37 Active bleeding (-) UC : good UFH : 2 fbu Wound of episiotomi : bleeding
1 day of VE
Time
subect
object
assesment
planning
17.45
18.10
Baby was born with vacuum extraction, male, AS : 3-5 , W : 3500 gr, caput + baby sent to NICU -Placenta was born, completed, spontaneously episiotomi
-Evaluate mother -Obs. VS
20.10
General condition : well BP: 100/60 mmHg P: 88x /m RR:18x/m T : 36,9C UC : good UFH = 2 finger below umbilical
4 stage of labor
07.00
General condition : well BP : 100/60 mmHg Pulse : 80x/mnt Rr : 16 x/mnt T: 37 Active bleeding (-)
1 day of VE
Time
subect Inspekulo in ER room : OUE CD (+), show tissue of placenta (+) VT : OUE CD (+), palpable tissue of placenta, CUAF b/c 14-16 APCD taa Therapy : Double line infus RL max drop. Insert catheter
object
assesment
planning
21.00
Abdominal pain >> Dizziness (+), weakness (+) Active bleeding (-)
General condition : moderate BP : 100/50 mmHg Pulse : 108x/mnt RR : 20x/mnt Tax : 37.8 C
22.00
General condition : weakness BP : 100/50 mmHg Pulse : 100/mnt RR : 22x/mnt Tax : 37.8 C
22.15
Time
subect
object
assesment
planning
23.00
General condition : moderate BP : 100/50 mmHg Pulse : 96x/mnt RR : 20x/mnt Tax : 37,5 C
Obs. VS
00.0006.00
07.00
07.00
General condition : well BP : 100/60 mmHg Pulse : 80x/mnt Rr : 16 x/mnt T: 37 Active bleeding (-)
1 day of VE