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    Audit Neonatal by Hernawati

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    Febiantsyif
    1) This document summarizes the medical records of a newborn over three days in the neonatal intensive care unit. 2) The newborn experienced respiratory distress and hypothermia shortly after a cesarean section birth and was diagnosed with neonatal asphyxia. 3) Over the next few days the newborn was treated with oxygen supplementation, antibiotics, steroids, and anticonvulsants but experienced further respiratory deterioration and went into cardiac arrest on the third day.

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    Audit Neonatal by Hernawati

    Uploaded by

    Febiantsyif
    3 views9 pages
    1) This document summarizes the medical records of a newborn over three days in the neonatal intensive care unit. 2) The newborn experienced respiratory distress and hypothermia shortly after a cesarean section birth and was diagnosed with neonatal asphyxia. 3) Over the next few days the newborn was treated with oxygen supplementation, antibiotics, steroids, and anticonvulsants but experienced further respiratory deterioration and went into cardiac arrest on the third day.

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    1) This document summarizes the medical records of a newborn over three days in the neonatal intensive care unit. 2) The newborn experienced respiratory distress and hypothermia shortly after a cesarean section birth and was diagnosed with neonatal asphyxia. 3) Over the next few days the newborn was treated with oxygen supplementation, antibiotics, steroids, and anticonvulsants but experienced further respiratory deterioration and went into cardiac arrest on the third day.

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    Download as pptx, pdf, or txt
    3 views9 pages

    Audit Neonatal by Hernawati

    Uploaded by

    Febiantsyif
    1) This document summarizes the medical records of a newborn over three days in the neonatal intensive care unit. 2) The newborn experienced respiratory distress and hypothermia shortly after a cesarean section birth and was diagnosed with neonatal asphyxia. 3) Over the next few days the newborn was treated with oxygen supplementation, antibiotics, steroids, and anticonvulsants but experienced further respiratory deterioration and went into cardiac arrest on the third day.

    Copyright:

    © All Rights Reserved
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    of 9

    AUDIT NEONATAL

    By Ny Hernawati

    Hari pertama
    17 januari 2016
    By lahir dari G3P2A0 dgn uk 36 mgg
    Ibu riwayat ANEMIA trombositopeni,plasenta previa,let su, dan
    riwayat sc
    Bayi lahir dg SC jam 10.45 wib, air ket kuning jernih, A/S 4/6,
    BB:2400 gr,PB: 46 cm, lK:32cm,lD:31cm, jenis kelamin:laki2
    By gerak kurang aktif,merintih,sesak,sianosis
    RR 67x/mnt,HR 140X/MNT
    Kepala: mesosepal,ubun2 datar
    Suhu : 35c
    Skor ballart: 30
    Diagnosa:NKB/SMK/SC/HIPOTERMI,ASFISIA RINGAN SEDANG

    Lapor dr sherly

    Advis dr Citra SpA


    Dex 5% 8tpm (perifer)
    Cefotaxim 2x120 mg
    Dexametason 2x6mg
    Aminipilin 3x0,3cc aa dex 5%
    Puasa,pasang OGT, cek DL,GDS

    Jam 13.00
    Hasil laborat di konsul ke dr
    febiola(dr jaga)
    Leukosit:1230x10^/ul,HB:14,0 gr/dl
    HT:
    43,2%,Trombosit:309x10/ul.GDS49
    mg/dl
    Retraksi (+)
    Advis :cek gds 1jam lg,section
    berkala
    Jam 16 lapor hasil gds 122 mg/dl

    18 januari 2016

    Menangis kurang kuat, gerakan kurang aktif,merintih,sesak,


    Ogt jernih
    Hr :110x/mnt, RR:72x/mnt Suhu: 36.3c
    Px lain2 sama spt hr pertama
    TERAPI:
    CPAP : peep 8, F1O2 60%
    Cefotaxim 2x120mg stop
    Gentamicin 2x6mg stop
    Di ganti meropenem 2x45 mg
    Deksametason 3x1 mg
    Aminopilin 3x0,3cc
    Puasa,awasi sesak,suhu

    Jam 02.05 wib


    Lapor dr jaga( dr leroy)
    By kejang,spo2 68%,nadi 170x/mnt,
    respirasi 90x/mnt, suhu 36,5
    Di berikan advis: phenobarbital 25
    mg im

    19 januari 2016
    Px fisik: by tampak pucat,menangis
    kurang ,gerak kurang aktif,
    sesak(+),OGT coklat
    HR 156x/mnt, RR 90x/mnt, Suhu 36,6
    Jam 09.45
    Bayi apnu (+), RR 18X/mnt,HR
    65x/mnt
    Advis dr Citra SpA:begging, adrenalin
    0,3cc iv
    Jam 10 45 asistol(+) dan by di

    TERIMAKASIH

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