CASE REPORT

Name

: Mrs. W

Age

: 20 years old

Address : Kekalik
Admitted

: 20/10/2012 at 17.30

TIME
20.45

SUBJECTIVE

OBJECTIVE

ASSESSMENT

UC : 4 x 10 ~ 40

PLANNING
Skin test Ampi
Injeksi 2 gr Ampi IV
Insert DC

22.05

CS began :
Baby was born: Female.
2800 gram, AS 1-3.
Anus (+), congenital
anomaly (-).

24.15

21/10/
2012
08.00

GC: well
Cons: CM
BP: 110/70 HR: 84 bpm
RR: 20 tpm
T: 36 C
UC: +
UFH: at umbilicus

2 hours post SC

GC: well
Cons: CM
BP: 110/80
HR : 82 bpm
RR : 20 tpm
T : 36,2 C
UFH : 1 finger below
umbilicus
UC : +
AB : -

1 day post SC

Baby in NICU:
PR:150
RR: 46
T: 37,4

Placenta was born

spontaneous, complete.
400
cc and
Bleeding
Observed
mother
baby well being
Suggest mother to
mobilization.
Observed mother and
baby well being
Suggest mother to
mobilization, eat, and
drink, medication.