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  • Bab Iii Follow Up: 11 September 2015 12 September 2015 S O Tanda Vital: Tanda Vital

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    Rika Susanti
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    - The patient is a 38-year-old female, post-cesarean section and myomectomy for placenta previa totalis. On follow-up examinations over 4 days, her vital signs were stable and physical examinations were normal. Her incision site showed improvement with decreased bleeding and drainage. She was receiving intravenous fluids, antibiotics, analgesics and other postpartum and post-surgical care. On the fourth day, her dressing was changed and she was approved for discharge with follow-up as an outpatient.

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    follow up

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    BAB 3 Follow up

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    - The patient is a 38-year-old female, post-cesarean section and myomectomy for placenta previa totalis. On follow-up examinations over 4 days, her vital signs were stable and physical examinations were normal. Her incision site showed improvement with decreased bleeding and drainage. She was receiving intravenous fluids, antibiotics, analgesics and other postpartum and post-surgical care. On the fourth day, her dressing was changed and she was approved for discharge with follow-up as an outpatient.

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    9 views3 pages

    Bab Iii Follow Up: 11 September 2015 12 September 2015 S O Tanda Vital: Tanda Vital

    Uploaded by

    Rika Susanti
    - The patient is a 38-year-old female, post-cesarean section and myomectomy for placenta previa totalis. On follow-up examinations over 4 days, her vital signs were stable and physical examinations were normal. Her incision site showed improvement with decreased bleeding and drainage. She was receiving intravenous fluids, antibiotics, analgesics and other postpartum and post-surgical care. On the fourth day, her dressing was changed and she was approved for discharge with follow-up as an outpatient.

    Copyright:

    © All Rights Reserved
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    of 3

    BAB III

    FOLLOW UP

    11 September 2015
    S
    O

    - Post sc
    Tanda Vital:
    - TD
    : 110/80
    - Nadi : 94x/menit
    - Suhu : 36,5OC
    - RR
    : 18x/menit
    -

    Pemeriksaan Fisik:
    Ku/kesadaran: baik/ CM
    Mata
    : SI-/-, CA-/Thorax : C/P dbn
    Abdomen
    : Bu(+) dbn
    Extremitas
    :
    AD ektremitas superior dan inferior -/OE ektremitas superior dan inferior -/-

    12 September 2015
    - Nyeri pada luka bekas operasi
    Tanda Vital:
    TD
    : 120/70
    Nadi : 80x/menit
    Suhu : 36,8OC
    RR
    : 22x/menit
    Pemeriksaan Fisik:
    Ku/kesadaran: baik/ CM
    Mata
    : SI-/-, CA-/Thorax : C/P dbn
    Abdomen
    : Bu(+) dbn
    Extremitas
    :
    AD ektremitas superior dan inferior -/OE ektremitas superior dan inferior -/-

    Status obstetri:
    - TFU sepusat
    -

    Status nifas dan gyn:


    ASI
    : +/+
    PPV
    : + (20 cc)
    Fl/fx
    : +/Bab/bak : -/+
    Flaktus
    :Status lokalis:

    DC vol 300 cc jernih post op jam


    13.00 kemarin
    Status obstetri:
    - Cut (+), TFU sepusat.
    -

    Status nifas dan gyn:


    ASI
    : +/+
    PPV
    : + ( 100 cc)
    Fl/fx
    : +/Bab/bak : +/+
    Flaktus
    :+
    Status lokalis:

    Perban
    Rembes
    Pus
    Darah
    Serum

    :+
    ::: -,
    :-

    Perban : +
    Rembes : 12

    Pus
    :Darah : Serum : P3A0 U 38 post sc + mow ai plasenta
    previa totalis H+1
    - Tx lanjut

    P3A0 U 38 post sc + mow ai plasenta


    previa totalis
    Terapi sesuai advice post sc:

    IVFD RL/D5 + 1 ampul oxytocin

    20 tpm
    Injeksi ketorolak 1ampul/8jam
    Injeksi ceftriakson 2x1gr/12 jam
    Mobilisasi bertahap
    Co-amoxiclav 3x1
    Asam mefenamat 3x1
    Bc/c 3x1
    SF 3x1
    Cek Hb

    13 September 2015
    S
    O

    - T.A.K
    Tanda Vital:
    - TD
    : 110/70
    - Nadi : 80x/menit
    - Suhu : 36,5OC
    - RR
    : 20x/menit

    14 September 2015

    - T.A.K
    Tanda Vital:
    TD
    : 130/90
    Nadi : 82x/menit
    Suhu : 36OC
    RR
    : 20x/menit

    Pemeriksaan Fisik:
    Pemeriksaan Fisik:
    Ku/kesadaran: baik/ CM
    - Ku/kesadaran: baik/ CM
    Mata
    : SI-/-, CA-/- Mata
    : SI-/-, CA-/Thorax : C/P dbn
    - Thorax : C/P dbn
    Abdomen
    : Bu(+) dbn
    - Abdomen
    : Bu(+) dbn
    Extremitas
    :
    - Extremitas
    :
    AD ektremitas superior dan inferior -/AD ektremitas superior dan inferior -/OE ektremitas superior dan inferior -/OE ektremitas superior dan inferior -/Status obstetri:
    Status obstetri:
    Cut (+) keras, TFU 2 jari di bawah - Cut (+) keras, TFU 2 jari di bawah
    pusat.
    pusat.

    Status nifas dan gyn:


    - ASI
    : +/+
    - PPV
    : + (20cc)
    - Fl/fx
    : + /-

    Status nifas dan gyn:


    - ASI
    : +/+
    - PPV
    : + ( 20 cc)
    - Fl/fx
    : +/-

    13

    - Bab/bak
    - Flaktus

    : +/+
    :+

    Status lokalis:

    A
    P

    Perban
    Rembes
    Pus
    Darah
    Serum

    :+
    ::::-

    - Bab/bak
    - Flaktus

    : +/+
    :+

    Status lokalis:

    Perban
    Rembes
    Pus
    Darah
    Serum

    :+
    ::::-

    P3A0 U38 post sc + mow ai plasenta


    P3A0 U38 post sc + mow ai plasenta
    previa totalis H+2
    previa totalis H+3
    Aff infus
    - Ganti Balut
    Aff DC
    - Boleh pulang
    Besok ganti balut
    - Tx lanjut
    Tx lain lanjut

    14

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