Professional Documents
Culture Documents
14 Nov 2008
14 Nov 2008
13 November 2008
2.
3.
4.
1.
5.
6.
Name
: Mrs. Muli
Age
: 32 years
Address
: Narmada
Subject
Wakt
u
04.4
5
pm
Patient
refered
by
Narmada
with
G1P0A0H0
aterm/single/life/intra uterine with
prolong of stage 1.
cronologis :
Patient felt intermitten abdominal
pain since 00.30 am (13-11-2008),
then she went to Narmada
Community Health Center as
soon, bloody show (-), and the
Center
found :
General status : well
BP : 110/70 mmHg
Pulse =80 x/mnt
RR: 20 x/mnt
Temp = 36C
UFL = 2 finger under xyphoideus
procesus.
Head presentation, desend 2/5.
VT : completed.
: 13 11 - 2008
: 04.30 pm
Object
Community
CTH
General status :
General condition: well,
Conciousness: CM
BP: 150/90
RR: 20 x/mnt
Pulse :88 x/mnt
T: 37,2 C
Eyes : an(-) ikt (-)
Cor -Pulmo : in normal range
Obstetric status :
L1 : breech
L2 : right back
L3 : head
L4 : desend 2/5
Uterine Fundal Length : 34 cm
EFW : 3565 g
His : (+) 3x/10~35
Fetal Heart Rate : 152 x/mnt
VT : completed, eff 100 %, amnionic
membrane (-), amniotic fluid (-)
meconeal, fontanella minor, descend
HIII, moulage (+1), small organ and
umbilical cord havent clear.
Assesment
Planning
G1P0A0H0
aterm/single/life/intra
uterine + neglected of
stage 2 +HDK
Observation
mother
and fetal well being.
Laboratory
examination : DL, UL,
HBsAg
Resusitation :
Reported
supervisor :
Advice : VE
to
Wakt
u
Subject
Object
Lab. result:
HBsAg (-)
HB = 11,6
WB = 26.800
TRB = 356.000
HMT = 35,1
Proteinuri (-)
Assesment
Planning
Time
Subject
05. 15
pm
Patient want
bearing down
to
RR: 20 x/mnt
Pulse :90 x/mnt
His : 4X/10~30
FHR : 156x/mnt
G1P0A0H0
aterm/single/life/intra
uterine + neglected of
stage 2 +HDK
Observation mother
fetal well being.
Prepare the VE set.
05.40
pm
Patient want
bearing down
to
BP: 150/90
RR: 20 x/mnt
Pulse :90 x/mnt
His : 4x/10~30
FHR : 140x/mnt
G1P0A0H0
aterm/single/life/intra
uterine + neglected of
stage 2 +HDK
Patient want
bearing down
to
RR: 20 x/mnt
Pulse :90 x/mnt
His : 4x/10~30
FHR : 140x/mnt
G1P0A0H0
aterm/single/life/intra
uterine + neglected of
stage 2 +HDK
05.50
pm
Object
Assesment
O6.00
pm
06.15 pm
Planning
stage IV of labor
and
Waktu
Subject
Object
Assesment
Planning
06.30 pm
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
Bleeding = -, lochia (+)
stage IV of labor
06.45 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
stage IV of labor
07.15 pm
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
stage IV of labor
07.45 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
Lochia rubra (+)
stage IV of labor
06.00 am
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
Bleeding = Lochia rubra (+)
Waktu
Subject
Object
Assesment
Planning
05.15 pm
BP = 110/80
RR= 20 x/mnt
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
stage IV of labor
05.30 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
stage IV of labor
05.45 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
stage IV of labor
06.00 am
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = Lochia rubra (+)