LAPORAN KASUS KEBIDANAN FIA AGUSTINA.pptx
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LAPORAN KASUS KEBIDANAN FIA AGUSTINA.pptx
- 1. LAPORAN KASUS KEBIDANAN RSIA FATIMAH
- 2. IDENTITAS PASIEN NAMA : NY F NAMA SUAMI :TN.F USIA/TGGL LAHIR : 32 TH / 3-08-1990 ALAMAT : JL RAYA PANGLIMA SUDIRMAN 001/004 PATOKAN TGGL MASUK : 08-04-2023 JAM 13.30 WIB
- 3. TANGGAL 8 APRIL 2023 JAM 13.30 WIB Rujukan PKM Pajarakan dengan G3 P1001 Ab1 uk 37 mgg T/H + BSC + Obesitas + makrosomia + Inpartu Kala 1 fase Laten.
- 4. Anamnesa PERJALANAN PERSALINAN Tanggal 8- 4 -2023 jam 01.00 WIB px mengatakan sakit perut, sakit perut semakin sering px periksa ke PKM pajarakan RIWAYAT OBSTETRI HPHT ; 23-07-2022 TP : 30-04-2023 TP USG : 30-04-2023 RIWAYAT PERSALINAN Anak 1 /SC/RSGS/LK/3900 gr/usia 7 Th Anak 2 /Abortus /kuret th 2022 Anak 3 hamil ini LAMA MENIKAH : 7 TH RIWAYAT KB :TIDAK ADA RIWAYAT PENYAKIT KELUARGA :TIDAK ADA
- 5. Hasil Pemeriksaan Tggl 08-04-2023 Jam 14.00 wib PEMERIKSAAN FISIK Keadaan Umum : cukup Kesadaran : composmentis TD : 138/87 mmHG Nadi : 99x/m suhu : 36,6 C RR : 22 x/m BB 110 KG TB 159 CM BMI 40,8 . STATUS OBSTETRI TFU : 43 cm PUKA TBJ : 4960 gr TBJ USG (6/4/2023) 4400 gr. DJJ :139 x/m His : 2.10.15 VT : 2 cm eff 25% ket (+) Preskep, Hodge 1 kepala sudah masuk PAP 4/5. Lakmus (-) bloodslym (+)
- 6. Hasil Pemeriksaan Penunjang DARAH LENGKAP Hemoglobin : 11,8 gr/dl Leukosit : 8.200 袖l Trombosit :185.000 袖l KIMIA URINE Protein Urine : +2 Glukosa urine : negatif
- 7. DIAGNOSA G3 P1001 AB1 UK 37 mgg T/H dengan BSC + KIFL + Makrosomia + Obesitas . Advice DPJP : - Siapkan SC (informed consent) - Premed - Profilaksis Pycin 1 gr (iv) - Lab DL , UL - Konsultasi SpAn
- 8. Tindakan yang dilakukan Infus RL (20 tpm) Pasang Kateter Inj Pycin 1 gr (iv) masuk jam 15.00 WIB Konsul Sp.An Advice Siapkan.
- 9. Follow Up TNGGAL 08-04-2023 Jam 18.00 WIB Pasien dikirim ke Ruang Operasi. Jam 18.45 WIB Bayi Lahir, JK : Laki-Laki. Jam 19.35 WIB SC Selesai, Pasien dipindah Ke Recovery Room. Hasil Pemeriksaan di RR : Keadaan umum : cukup GCS : 456 TD : 124/70 mmHg S : 36 C Nadi : 80 x/m Spo2 : 99%
- 10. FOLLOW UP JAM 20.30 Pasien dipindah ke Ruang Nifas Tx Post Op : - Inf RL : D5 : 2:3 (24 jam) - Injeksi Furamin 1x1 - Injeksi Dexketoprofen : 3x1 - Injeksi Metoclopramid : 3x1 - Observasi perdarahan, Intake Output,dan K/U Pasien - Cek Hb
- 11. Follow Up Tggl 09-04-2023 Jam 12.00 wib Keluhan : taa k/u : cukup TD : 128/66 mmHG Nadi : 76 x/m Suhu : 36,5 C Flatus (+) Mobilisasi (+) jalan Diit :TKTP Hb Post Op ; 10,9 gr/dl Jam 12.00 WIBVisite DPJP Advice : - Pro KRS - Rawat Luka kering , pus (-) - Obat Pulang : Cefadroxil 2x1,Asmef 3x1, Paracetamol 1gr 3x1 - Kontrol TGGL 13/4/2023 Ke Poli Kandungan RSIA Fatimah PasienTidak Kontrol
- 12. Follow Up Tggl 09-4-2023 Jam 16.00 WIB Pasien dipulangkan.