Age: 18 Years Address: Pringgarata: Time Subject Object Assesment Planning
Age: 18 Years Address: Pringgarata: Time Subject Object Assesment Planning
Age: 18 Years Address: Pringgarata: Time Subject Object Assesment Planning
: Ny. H
age
: 18 years
Address
: Pringgarata
Admitted
: 08 12 09
: 10.15
Time
Subject
Object
Assesment
Planning
10.15
General status :
General condition: good
Conciousness: CM
BP: 140/100 mmHg
RR: 24 x/mnt
PR: 80 x/mnt
T: 37 C
Eyes : an(-), ikt (-)
Cor -Pulmo : in normal range
Extremitas : oedem in lower
extremitas
G2P0A1H0 A/S/L/IU
head presentation
with PER
Chronologis :
Patient came to Bagu PHC at 09.15
(08/12/09)
confess
abdominal
pain
(+).
Hipertention (-), DM (-),
asma (-).
examination in PHC:
General condition : good
Conciousness: CM
BP : 140/100 mmHg
RR : 20 x/mnt
Edem : +
UFH : 38 cm
FHR : 138 bpm
VT: CD 2 cm, eff 30%, ket (+) head
presentation
ANC : >8 x at Polindes , last about
2 weeks ago.
Obstetric status:
1.
Abortus, 4 month
2.
This pregnant
History of contraception:Planning contraception:-
Obstetric status :
L1 : breech
L2 : left back
L3 : head
L4 : wasnt pelvic inlet, 5/5
UFH 38 cm
EFW : 4030 g
UC : 2 x 10 ~ 20
FHR : 152 bpm
VT : 1 cm, eff 10 %, AM
(+), head palpable, descend
HI,
denominator
unclear,
unpalpable small organ and
umbilical cord.
Time
Subject
Object
Lab examination :
Hb : 12,5 gr%
Leukosit : 5,86 %N
Trombosit : 171 K/ul
HCT : 37,9%
HbsAg : Proteinuri : +2
Pelvic score :
Assesment
Planning
Time
Subject
Object
Assesment
Planning
11.15
Observation
hour again
vital
sign
12.15
Observation
hour again
vital
sign
13.15
Observation
hour again
vital
sign
21.30
Dizziness (+)
Abdominal discomfort (+)
G2P0A1H0
A/S/L/IU
head
presentation
with PEB
Time
02.00
(091209)
Subject
Object
Assesment
SC begun
Planning
Baby was born male, weight
4800g, length 50 cm, AS 7-9
Placenta was born complete, 1
minute after baby was born
04.00
BP : 160/90 mmHg
PR : 84 x/mnt
RR : 20 x/mnt
T : 36C
UC : good
UFH : 2 cm below umbilical
Wound of operation: good
Baby:
HR: 140 bpm
RR: 36 bpm
T: 36,6 C
2 hours post SC
07.00
BP : 160/90 mmHg
PR : 84 x/mnt
RR : 20 x/mnt
T : 36C
UC : good
UFH : 2 cm below umbilical
Wound of operation: good
Baby:
HR: 146 bpm
RR: 36 bpm
T: 36,7 C
1 day post SC