Escolar Documentos
Profissional Documentos
Cultura Documentos
2
3 4 3
Severe preeclampsia
Neglacted I stage of labor + oligohydroamnion Placenta previa Normal labor
2
1 1 2
Admitted
: 02-07-2009 : 11.00
Time 11.00
Subject Patient referred from labuapi PHC with G1P0A0 43 weeks / single/life with postterm pregnancy Chronologis : Patient came to labuapi PHC with pregnancy more than 9 month. Abdominal discomfort (-), vaginal discharge ().from examination found : BP : 120/70 mmHg Pulse : 84x/ RR : 18x/ T : 36,2 C LMP : 06/09/08 EDD : 13/06/09 Obstetri history : 1.This
Object General status : General condition: well, Conciousness: CM BP: 120/80 mmHg RR: 20 x/mnt PR: 88 x/mnt T: 36,8 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : breech L2 : left back L3 : left back L4 : head UFH 28 cm EFW : 2635 g UC : (-) Fetal Heart Rate : 12 12 13 VT : servic dilatation 1 cm, AM (+), H1, wasnt not palpable small organ or umbilicus,
Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg Report to supervisor propossed to drip oxytocin advice : CTG. if CTG good, drip oxytocin
Time
Subject
Object
Lab examination found :
Assesment
Planning
CTG (base line 145, deselerasi 120) Report to supervisor (13.00), Propossed : drip oxytocin 5 UI in 500 cc D5% Propossed agree Start drip oxytocin seri I, flash 1 8 drops/mnt Observation mother and fetal well being
13.30
14.00
Start drip oxytocin seri I, flash 1 12 drops/mnt Observation mother and fetal well being
14.30
Start drip oxytocin seri I, flash 1 16 drops/mnt Observation mother and fetal
Time
15.00
Subject
Abdominal discomfort (-)
Object
General status : well FHB : 12 12 13 UC : General status : well FHB : 12 12 13 UC : General status : well FHB : 12 13 12 UC : -
Assesment G1P0A0 42-43 weeks/single/life with post term pregnancy G1P0A0 42-43 weeks/single/life with post term pregnancy G1P0A0 42-43 weeks/single/life with post term pregnancy G1P0A0 42-43 weeks/single/life with post term pregnancy
Planning
Start drip oxytocin seri I, flash 1 20 drops/mnt Observation mother and fetal well being Start drip oxytocin seri I, flash 1 24 drops/mnt Observation mother and fetal well being Start drip oxytocin seri I, flash 1 28 drops/mnt Observation mother and fetal well being Start drip oxytocin seri I, flash 1 32 drops/mnt Observation mother and fetal well being Start drip oxytocin seri I, flash 1 36 drops/mnt Observation mother and fetal well being
15.30
16.00
16.30
17.00
17.30
Start drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being
Time
18.00
Subject
Abdominal discomfort (-)
Object
General status : well FHB : 13 13 12 UC : General status : well FHB : 13 13 12 UC : General status : well FHB : 12 13 12 UC : General status : well FHB : 13 13 13 UC : 2x/10 ~ 20
Assesment G1P0A0 41 weeks / single/life with postterm pregnancy G1P0A0 41 weeks / single/life with postterm pregnancy G1P0A0 41 weeks / single/life with postterm pregnancy G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor.
Planning
maintenance drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being maintenace drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being maintenace drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being
18.30
19.00
19.30
VT : 1 cm, eff 25 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
20.00 Abdominal discomfort (+) General status : well FHB : 12 12 13 UC : 2x/10 ~ 20
maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being
Time
20.30
Subject
Abdominal discomfort (+)
Object
General status : well FHB : 13 12 13 UC : 2x/10 ~ 20 General status : well FHB : 12 12 13 UC : 2x/10 ~ 20 General status : well FHB : 12 12 13 UC : General status : well FHB : 13 13 13 UC : 2x/10 ~ 20
Assesment G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor.
Planning
maintenace drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenace drip oxytocin seri I, flash 1 40 drops/mnt Observation mother and fetal well being maintenace drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being
21.00
21.30
22.00
22.30
maintenace drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being
23.00
Time
23.30
Subject
Abdominal pain (+)
Object
General status : well FHB : 13 12 13 UC : 2x/10 ~ 20 General status : well FHB : 12 12 13 UC : 2x/10 ~ 20
Assesment G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor. G1P0A0 41 weeks / single/life with latent phase of Ind stage of labor.
Planning
Drip oxytocin failure Rest 24 hours Observation mother and fetal well being Observation mother and fetal well being Test ampi, injeksi ampicilin 1 gr Observation mother and fetal well being
21.45
08.30
11.45
VT : 3 cm, eff 25 %, amniotic membrane (-), head palpable, descend HI, unpalpable small organ and umbilical cord.
Time
15.00
Subject
Abdominal (+) discomfort
Object General status : well FHB : 12 12 12 UC : (-) VT : 1 cm, eff 10 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
General status : well FHB : 12 12 11 UC : (-)
Assesment G1P0A0 41 weeks / single/life with aktive phase of Ind stage of labor.
Planning
Observation mother and fetal well being
17.30
VT : 1 cm, eff 10%, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
17.45 Mother want to bearing down Doran teknus perjol vulka
Conduct mother to bearing down Observation mother and fetal well being every 2 hours Failure conduct bearing down mother to
22.30
Time 21.00
Assesment G1P0A0 41 weeks / single/life 2nd stage of labor. 2nd stage of labor.
22.15
22.45
23.45
Admited
: 19/04/09 : 14.45
Time 14.45
Subject Patient referred from Ampenan PHC with G1P0A0 1st stage labor Cronologist : Patient came to PHC ( 14.00 /18 04 09) with vaginal discharge .+ abdominal discomfort. examination found in PHC : BP : 140/90 mmHg Pulse : 82x/ RR : 22x/ T : 36 C VT : Servic dilatation 3 cm, eff 25 %, AM (-), H1,wasnt not palpable small organ or umbilicus, oedema servic FHR : 12-121-12 UC : 2x/10~25
LMP = forgotten in VK : patient felt abdominal discomfort ++, fetal
Object General status General condition : well Consciousness : CM BP : 170/100 mmHg PR : 84x/mnt RR : 24x/mnt T : 36.8 C Eye : an (-), ict (-) Pulmo,cor : in normal range Extr : udem minimal Obstetric status L1 : breech, UFH : 35 cm L2 : right back L3 : head L4 : decendsus 4/5 UC : 2-3x/10~30 FHR : 12-13-13 EFW : 3720 g VT : servic dilatation 3 cm, servic oedema, AM (-), H1, wasnt not palpable small organ or umbilicus, Hb : 11.7 Leu : 20.700 PLt : 270.000
Assesment G1P0A0 A/S/L 1st stage labor latent fase+ severe preeclampsia+ vaginal discharge history
Planning Obs.mother and fetal well being Obs vital sign and urine produce CTG : BL 150 Check lab : UL, DL, HBs Ag Report to supervisor Supervisor not available
time
17.30
Subject
Object
Assesment
Planning
Report to supervisor : Advice inject antibiotic Bolus MgSO4 4 g in 20 cc aquabidest Drip MgSO4 6 g in infuse 28 drops/mnt Educated mother to left down
18.45
BP : 170/ 90 Pulse : 100x/ RR : 22x/ UC : 3x/10~ 30-40 VT : servic dilatation 4 cm, eff 50 %, AM (-), head palpable, H1, wasnt palpable small organ FHR : 12-13-12 BP : 170/80 Pulse : 120x/ RR : 22x/ Urine produce : 300 cc
Observation of mother and fetal well being Educated mother to eating and left down. Observation 4 h again.
21.00
G1P0A0 A/T/H 1st stage labor active fase + severe preeclampsia G1A0P0 protacted 1st stage labor active fase + severe preeclampsia + febris
22.45
Abdomnal discomfort +++, patient felt epigastrial pain , diplopia (-), vomiting (-),
BP : 160/100 Pulse : 100x/ RR : 22x/ T : 38,2 C VT : servic dilatation 4 cm, eff 50 % , AM (-), head presentation,
time
23.50
Subject
Object
Assesment
Planning
Baby was born, 3700 g, female, AS : 6-7 Placenta was born, complete Baby move to nicu
07.00
Admitted
: 19-04-2009 : 16.00
Time
16.00
Subject
Patient came to Emergency Room G4P3A0H3 Aterm/single/life/intrauterin with hipertensi and bleeding from vagina et causa plasenta previa Cronologist: 15.54 (19/04/09) patient came to emergency room because bleeding from vagina since 01.30 (19-04-09), abdominal pain since 12.00 (19-04-09), from examination found : BP : 190/130 RR : 90 x/mnt LMP: forgot Obstetric Status: 1.Male, aterm, spontan, Traditional attendent, 15 years. 2.Female, aterm, spontan, traditional attendent, 13 years. 3.Male, aterm, spontan, traditional attendent, 7 years 4.This
Object
General Status:
Assesment
G4P3A0H3 Aterm/single/life/intr auterin with bleeding from vagina et causa plasenta previa
Planning
Observ mother and fetal Laboratorium examination: Blood, HBsAg Report to superisor, proposed: observation,antibiotik proposed: agree
General condition: well Conciousness: CM BP: 130/100 mmHg RR: 24 x/mnt PR: 88 x/mnt T: 37 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status: L1 : breech, UFH: 32 cm L2 : left back L3 : head L4: wasnt in Pelvic Inlet EFW : 3250 g UC : Fetal Heart Rate : 12-12-13 VT : not done Inspeculo: dilatation of cervix (-), bleeding (+) 200cc
Time
History of
Subject
family planning:
Object
Lab. Result: Hb: 9.3g % WBC: 11.100 /mm3 Trombosit : 221000 /mm3 Hct: 27.5 HBsAg: (-)
Assesment
Planning
injection 3 month
family planning: MOW
G4P3A0H3 Aterm/single/life/intr auterin with bleeding from vagina et causa plasenta previa
Obs. Mother and fetal well being Ampicillin test (-) and injection ampicillin 1 g/IV
21.30
G4P3A0H3 Aterm/single/life/intr auterin with bleeding from vagina et causa plasenta previa
Obs. Mother and fetal well being Report to supervisor, propossed SC, propossed agree Prepare to SC
Time
22.15
Subject
Object
Assesment
G4P3A0H3 Aterm/single/life/intr auterin with bleeding from vagina et causa plasenta previa
Planning
SC Begun
22.40
Baby was born male, weight 2450g, length 48 cm, AS 7-8. baby admited to NICU
00.40
Admitted
: 18-04-2009 : 20.55
Time
20.55
Subject
Patient refered by dr. K. Tresna Sp.OG G1P0A0H0 39 - 40 weeks Single / life / intrauterine with oligohidramnion. Chronologiest : 19.00 pm (18 04 09) Patient came to dr. K. Tresna with intermitten abdominal pain since 16.00 (18 04 09). From examination found : UFH : 34 cm, FHR:140x/mnt UC : 1 - 2x/10 ~ 10 VT : 3 cm, eff 30 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. Advice from dr. K. Tresna : drip oxytocin and report to supervisor in VK Last menstrual period : 20-07-08 EDD : 27-04-09 History of family planning : Family planning : injection 3 month ANC : routine in polindes
Object
General Status:
Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with
Planning
Observ mother and fetal Laboratorium examination: Blood, HBsAg Report to superisor, proposed: observation, proposed: agree
General condition: well Conciousness: CM BP: 110/70 mmHg RR: 20 x/mnt PR: 88 x/mnt T: 36,8 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status: L1 : breech, UFH: 34 cm L2 : left back L3 : head L4: was in pelvic inlet 4/5 EFW : 3565 g UC : 1 - 2x/10 ~ 10 Fetal Heart Rate : 12 - 11 - 12 VT : 3 cm, eff 30 %, amniotic
membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
with head
Time
Subject
Object Lab examination found : Hb : 13.6 gr% Leukosit : 9700/mm3 Trombosit : 178000/mm3 Hematocrit : 37.6
Assesment
Planning
01.00 (19/04/09)
General condition: well BP: 110/70 mmHg FHR : 12 12 13 UC : 1 - 2x/10 ~ 10 VT : 3 cm, eff 40 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. General condition: well BP: 110/70 mmHg FHR : 12 12 13 UC : 1 - 2x/10 ~ 10 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. General condition: well BP: 110/70 mmHg FHR : 12 12 13 UC : 2 - 3x/10 ~ 20 - 25 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
04.00
stage of labor +
oligohidramnion.
08.00
stage of labor +
oligohidramnion.
Time
10.00
Subject
Abdominal discomfort (+)
Object
General condition: well BP: 110/70 mmHg FHR : 12 12 13 UC : 2 - 3x/10 ~ 20 - 25 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord.
Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active
Planning
Obs. Mother and fetal well being Report to supervisor, propossed oxytocin drip 5 UI in 500 cc D5%, propossed agree
Bishop score : 6
10.30 Abdominal discomfort (+) General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active Start drip oxytocin seri I, flash 1 8 drops/mnt Observation mother and fetal well being
Time
12.00
Subject
Abdominal discomfort (+)
Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25
Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active
Planning
Start drip oxytocin seri I, flash 1 20 drops/mnt Observation mother and fetal well being
Time
14.00
Subject
Abdominal discomfort (+)
Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25
Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active
Planning
Start drip oxytocin seri I, flash 1 36 drops/mnt Observation mother and fetal well being
14.30
Time
16.00
Subject
Abdominal discomfort (+)
Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25 VT : 4 cm, eff 50 %, amniotic membrane (+), head palpable, descend HI, unpalpable small organ and umbilical cord. General status : well FHB : 12 12 12 UC : 2 - 3x/10 ~ 20 - 25
Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active
Planning
Start drip oxytocin seri I, flash 1 finish Observation mother and fetal well being
16.30
maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being
Time
18.00
Subject
Abdominal discomfort (+)
Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25
Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase
Planning
maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being Report to supervisor, propossed SC, propossed agree. maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being
19.30
Time
20.00
Subject
Abdominal discomfort (+)
Object
General status : well FHB : 12 12 11 UC : 2 - 3x/10 ~ 20 - 25
Assesment
G1P0A0H0 39 - 40 weeks Single / life / intrauterine with negleted active phase
Planning
maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being Report to supervisor, propossed SC, propossed agree. maintenance drip oxytocin seri I, flash 2 40 drops/mnt Observation mother and fetal well being
21.30
Prepare to SC
Time
22.00
Subject
Object
Assesment
Planning
SC begun
23.08
Baby was born female, weight 3500g, length 50 cm, AS 7-8 Placenta was born complete,weight 450 g, length 50 cm
Hemorrage : 150cc
00.00 General status : well BP : 130/80 mmHg PR : 88 x/mnt RR : 20 x/mnt UC : good UFH : 2 cm below umbilical General status : well BP : 130/80 mmHg PR : 88 x/mnt RR : 20 x/mnt UC : good UFH : 2 cm below umbilical
01.00
Admitted
: 19-04-2009 : 11.10
Time
11.10
Subject
Patient referred from PKM Ampenan G4P3A0H0 Aterm/single/life with breech presentation + PROM > 12 hours Cronologist: 06.30 (19/04/09) patient came to PKM Ampenan because patient confess vaginal discharge since 02.00 (19-04-09). Abdominal discomfort (-). From examination found: BP : 100/70 mmHg PR : 84 x/mnt RR : 22 x/mnt T : 36,8C UC : FHR : 11 11 12
Object
General Status:
Assesment
G4P3A0H3 Aterm/single/life with breech presentation + PROM > 12 hours
Planning
Observ mother and fetal Laboratorium examination: DL, HBsAg Skin test ampi, injeksi ampicilin 1 gr Report to superisor, proposed: Oxytocin drip 5 UI in 500cc D5%, proposed: agree
General condition: well Conciousness: CM BP: 110/70 mmHg RR: 20 x/mnt PR: 84 x/mnt T: 36,6 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status: L1 : head L2 : left back L3 : breech L4: wasnt in pelvic inlet UFH: 30 cm AC : 98 cm EFW : 2940 g UC : Fetal Heart Rate : 12 - 11 - 11 VT : not done Bishop Score : 6
VT : 1 cm, eff 10 %, amniotic membrane (+), descend HI, palpable small organ
Time
Subject
Last menstrual period : forgot History of family planning : injection 3 month Family planning : injection 3 month ANC : routine in polindes Obstetric history: 1.This
Object
Lab examination found: Hb : 9,5 gr% Leukosit : 14.000/mm3 Trombosit : 392.000/mm3 Hematokrit : 28.5
Assesment
Planning
14.00
Start drip oxytocin seri I, flash 1 8 drops/mnt Observation mother and fetal well being
17.