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    Clinical Pathway Letak Sungsang Primigravida 2017

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    Nina Muzaina
    This document is a clinical pathway for a primigravid woman with a breech presentation. It outlines the patient's diagnosis, assessments, treatments, medications, procedures, education, and planned discharge. These include vital sign monitoring, ANC checks, ultrasound, IV fluids, antibiotics, analgesics, a cesarean section, wound care, mobilization instructions, and a post-op follow up plan. The clinical pathway is intended to standardize care over three inpatient hours for this condition.

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    Clinical Pathway Letak Sungsang Primigravida 2017

    Uploaded by

    Nina Muzaina
    27 views2 pages
    This document is a clinical pathway for a primigravid woman with a breech presentation. It outlines the patient's diagnosis, assessments, treatments, medications, procedures, education, and planned discharge. These include vital sign monitoring, ANC checks, ultrasound, IV fluids, antibiotics, analgesics, a cesarean section, wound care, mobilization instructions, and a post-op follow up plan. The clinical pathway is intended to standardize care over three inpatient hours for this condition.

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    This document is a clinical pathway for a primigravid woman with a breech presentation. It outlines the patient's diagnosis, assessments, treatments, medications, procedures, education, and planned discharge. These include vital sign monitoring, ANC checks, ultrasound, IV fluids, antibiotics, analgesics, a cesarean section, wound care, mobilization instructions, and a post-op follow up plan. The clinical pathway is intended to standardize care over three inpatient hours for this condition.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    27 views2 pages

    Clinical Pathway Letak Sungsang Primigravida 2017

    Uploaded by

    Nina Muzaina
    This document is a clinical pathway for a primigravid woman with a breech presentation. It outlines the patient's diagnosis, assessments, treatments, medications, procedures, education, and planned discharge. These include vital sign monitoring, ANC checks, ultrasound, IV fluids, antibiotics, analgesics, a cesarean section, wound care, mobilization instructions, and a post-op follow up plan. The clinical pathway is intended to standardize care over three inpatient hours for this condition.

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    CLINICAL PATHWAY

    LETAK SUNGSANG PRIMIGRAVIDA


    2017

    RSIA SELASIH MEDIKA


    Jl. Bintara Raya No. 5

    Nama Pasien : Umur: Berat badan: Tinggi badan: No. CM:

    Diagnosa Awal: Kode ICD-10: Rencana rawat : Target 3 hr Respon Time/waktu:


    Aktivitas Pelayanan R.Rwt: Tgl/jam masuk: Tgl/jam keluar: Lama rwt: Kelas Tarif /Hr (Rp) Biaya (Rp)

    Hr.Rwt 1 Hr.Rwt 2 Hr.Rwt 3


    Hr Sakit Hr Sakit Hr Sakit
    Diagnosis
     Penyakit Utama Letak sungsang Letak sungsang Letak sungsang
     Penyakit
    Penyerta
     Komplikasi
    Assesment Klinis
     Pemeriksaan  Tanda Vital  Tanda Vital  Tanda Vital
    Dokter  ANC  Bising usus  Bising usus
     Luka operasi  Luka operasi
     Konsultasi bagian lain  Anastesi
     Internis
     lain
    Pemeriksaan Penunjang  DL
     BT,CT
     GDS
     Ureum
     Kreatinin
     USG
    Tindakan  Sectio Caesaria  IVFD RL 2L/hari
     IVFD RL 2L/hari
     Oksigen .... l/m
     Pasang kateter
    Obat-obatan Injeksi Injeksi Obat Oral
     Methergin  Cefoferazone  Cefadroksil
     Cefoferazone  Metronidazole
     Extra C drip Obat oral  Asam Mefenamat
     Profenid supp  Asam mefenamat  B Comp C
     B Comp C
    Obat anestesi
     Midazolam Infus
     Gas anestesi  RL
     Bupivacain  Nacl

    Infus
     RL
     Nacl
     D 5%
    Nutrisi  Puasa  Makan Lunak  Makan Berat

    Mobilisasi  Tirah Baring  Duduk di tempat tidur  Aktifitas harian mandiri


    Outcome (hasil)  Nyeri daerah operasi  Nyeri daerah operasi  Nyeri daerah operasi
     Luka operasi  Luka operasi  Luka operasi
     ....................………  ......................……  ......................…………
    Edukasi  Penjelasan mengenai  Penjelasan mengenai  Penjelasan mengenai
    perkembangan perkembangan perkembangan
    penyakit berkaitan penyakit berkaitan penyakit berkaitan
    dengan terapi dan dengan terapi dan dengan terapi dan
    tindakan yang sudah tindakan yang sudah tindakan yang sudah
    dilakukan dilakukan dilakukan
    Rencana Pulang  Kontrol poliklinik
    Varians
    Jumlah biaya
    Nama Perawat Diagnosa akhir Kode ICD-10 Jenis tindakan Kode ICD-9-CM
    Letak sungsang O 32.2 Sectio Caesaria elektif 74.4
    primigravida
    Nama Dokter Penyerta
    Nama pelaksana verifikasi Komplikasi

    Jakarta, 2017

    DOKTER PENANGGUNG JAWAB

    ( )

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