29-10-2012 ppi

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  • 8/13/2019 29-10-2012 PPI

    1/6

    Name : Mrs. V

    Age : 23 yo

    Adress : PagesanganAdmitted : October, 28th2012 at 20.00

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    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    28/10/

    2012

    20.00

    Patient referred from Permata

    Hati clinic with G1P0A0L0 30-31

    weeks S/L/IU head presentation

    with latent phase 1st stage of

    labor . Patient complaint

    abdominal pain since 10.00(27/10/2012). History of rupture

    of membrane (-), bloody slim (+)

    since 10.00 (27/10/2012).

    No history of DM, HT, asthma.

    LMP : 01/04/2012

    EDD : 08/01/2013

    History of ANC : 3xLast ANC : (-)

    History of USG : 1x

    History of family planning : (-)

    Next family planning :(-)

    Obstetrical History :

    I. Ini

    Chronologist (-)

    General Status

    GC : well

    Consciusness : CM

    BP : 130/80 mmHg

    PR : 112 bpm

    RR : 24 bpm

    T : 37 C

    Eye : anemis (-/-), icteric (-/-)

    Cor : S1S2single reguler, M (-), G (-)

    Pulmo : vesikuler (+/+), wheezing (-

    /-), ronkhi (-/-).

    Abdomen : scar (-), striae (+), linea

    nigra (+).Extremity : edema (-/-), warm acral

    (+/+)

    Obstetrical Status

    L1 : breech

    L2 : back on the left side

    L3 : head

    L4 : 4/5

    UFH : 33 cmEFW : 3410 g

    UC :2x/10 ~ 25

    FHB : 11-10-10 (124 bpm)

    VT : 2 cm, eff 20%, amnion (+),

    head palpable HI +, denominator

    unclear, impalpable small part /

    umbilical cord.

    G1P0A0L0 40-41

    weeks S/L/IU with

    latent phase 1st

    stage of labor and

    gestational

    hypertension

    Observe pervaginam

    delivery using

    partograf

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    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    Pelvic Evaluation :

    Spina ischiadica not prominent

    Os coccigeous mobile

    Pubic arch > 900

    Lab Evaluation

    HB : 8,6 g/dl

    RBC : 5,39 M/dl

    HCT : 31,1 %

    WBC : 12,83 K/dl

    PLT : 487 K/dl

    HbSAg : (-)Proteinuria : (-)

    13/08/

    2012

    00.00

    Mother confessed water

    came out from her womb

    GC well

    BP : 130/90 mmHg

    PR : 80 bpm

    RR : 20 bpm

    T : 36oC

    UC : 3x/10~30

    FHB : 12-12-12(144 bpm)VT : 4 cm, eff 50%, amnion

    (-), head palpable HI, denom

    unclear, unpalpable small part /

    umbilical cord.

    G1P0A0 40-41

    weeks S/L/IU head

    presentation with

    active phase 1ststage

    of labor + ROM +

    gestational

    hypertension

    Suggest mother lay to the

    sideways, eat, and drink.

    Observe pervaginam

    delivery using partograf

    Inj. Ampicilin 1 g/IV

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    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    13/08/

    2012

    04.00

    Mother confessed abdominal

    pain (+++)

    GC : well

    BP : 130/90 mmHg

    PR : 80 bpmRR : 20 bpm

    T : 36,7oC

    UC : 3x/10~35

    FHB : 13-12-12 (148 bpm)

    VT : 4 cm, oedem on portio,

    amnion (-), head palpable,

    caput (+), HI, unpalpable

    small part / umbilical cord.

    G1P0A0 40-41 weeks

    S/L/IU head

    presentation witharrested active phase

    1st stage of labor and

    gestational

    hypertension

    Suggest mother lay to the

    sideways, eat, and drink.

    Observe pervaginamdelivery using partograf

    DM co to SPV, pro

    acceleration. Advice :

    Rehydration and

    evaluation 2 hours again

    06.00 Mother confessed abdominal

    pain (+++)

    GC well

    BP : 130/80 mmHg

    PR : 82 bpm

    RR : 20 bpm

    T : 37oC

    UC : 2x/10~25

    FHB : 13-12-12 (148 x/min)

    VT : 4 cm, oedem on portio,amnion (-), head palpable,

    caput (+) H-II, unpalpable

    small part / umbilical cord.

    G1P0A0 40-41 weeks

    S/L/IU head

    presentation with

    arrested active phase

    1st stage of labor and

    gestational

    hypertension

    DM co to SPV, advice :

    acceleration with drip

    oxytocin began 16 tpm

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    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    06.30 Abdominal pain (+) UC : 2x/10~25

    FHB : 11-11-11(132 bpm)

    Drip oxytocin began

    16 tpm

    07.00 Abdominal pain came and relieved UC : 3x/10~30

    FHB : 12-11-11 (136 bpm)

    Drip oxytocin 20 tpm

    07.30 Abdominal pain came and relieved UC : 3x/10~30

    FHB : 12-11-12 (140 bpm)

    Drip oxytocin 24 tpm

    08.00 Abdominal pain came and relieved UC : 3x/10~35

    FHB : 12-12-12 (144 bpm)

    Drip oxytocin 28 tpm

    08.30 Abdominal pain came and relieved UC : 4x/10~40

    FHB : 11-12-12 (140 bpm)

    Drip oxytocin 32 tpm

    Maintenance

    09.00 Abdominal pain came and relieved

    A : G1P0A0 40-41 weeks S/L/IU head

    presentation with inpartu active phase 1ststage of labor + ROM

    P :

    Suggest mother lay to the sideways, eat,

    and drink.

    Observe mother and fetal well being

    Observe progress of labor

    GC well

    BP : 140/90 mmHg

    PR : 108 bpmRR : 22 bpm

    T : 37oC

    UC : 4x/10~35

    FHB : 12-13-12 (148 bpm)

    VT : 8 cm, oedem on

    portio, amnion (-), head

    palpable, caput (+), HI,

    unpalpable small part /

    umbilical cord.

    G1P0A0 40-41

    weeks S/L/IU

    headpresentation with

    arrested active

    phase 1st stage

    of labor and

    gestational

    hypertension

    Drip oxytocin 32 tpm

    Observe pervaginam

    delivery usingpartograf

    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

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    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    11.55 Baby was born

    Spontan, female, BB 3500

    g, PB 54 cm, AS 7-9, anus

    (+), congenital anomaly (-),

    Plasenta was born

    Spontaneus, completed

    Bleeding : 150 cc

    Perineum Episiotomy (+)

    14.00 GC : well

    BP : 130/80 mmHg

    PR : 88 bpm

    RR : 20 bpm

    T : 37o

    CUC : (+) well

    UFH : 2 finger below umbilicus

    Active bleeding : (-)

    2 hours post

    partum

    Observed mother and

    baby well being.

    Suggest mother to

    mobilisation.

    14/08/

    2012

    07.00

    Delivery wound pain GC : well

    BP : 110/80 mmHg

    PR : 88 bpm

    RR : 20 bpm

    T : 36,40CUFH : 3 finger below umbilicus

    UC : (+) well

    Lochea rubra : (+)

    Baby rooming in :

    PR :144 bpm

    RR : 46 bpm

    T : 36,40C

    One day post

    partum

    Observed mother and

    baby well being

    Suggest mother to

    mobilisation, eat, and

    drink, medication.