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    CP Partus Kasep

    Uploaded by

    Salman Faridzi
    This document summarizes a 4-day clinical pathway for a patient admitted with a diagnosis of cephalopelvic disproportion (CPD). It includes the patient's name, age, vital signs, diagnosis, treatment plan and activities during each day of admission. The patient received IV fluids, antibiotics, pain medications, mobilization and monitoring. Procedures included normal vaginal delivery assisted with vacuum extraction and suturing of perineal tears. The patient's condition stabilized with no infections or bleeding and she was discharged on the fourth day with nutrition and postpartum care instructions.

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    CP Partus Kasep

    Uploaded by

    Salman Faridzi
    120 views3 pages
    This document summarizes a 4-day clinical pathway for a patient admitted with a diagnosis of cephalopelvic disproportion (CPD). It includes the patient's name, age, vital signs, diagnosis, treatment plan and activities during each day of admission. The patient received IV fluids, antibiotics, pain medications, mobilization and monitoring. Procedures included normal vaginal delivery assisted with vacuum extraction and suturing of perineal tears. The patient's condition stabilized with no infections or bleeding and she was discharged on the fourth day with nutrition and postpartum care instructions.

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    Template clinical pathway partus kasep

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    This document summarizes a 4-day clinical pathway for a patient admitted with a diagnosis of cephalopelvic disproportion (CPD). It includes the patient's name, age, vital signs, diagnosis, treatment plan and activities during each day of admission. The patient received IV fluids, antibiotics, pain medications, mobilization and monitoring. Procedures included normal vaginal delivery assisted with vacuum extraction and suturing of perineal tears. The patient's condition stabilized with no infections or bleeding and she was discharged on the fourth day with nutrition and postpartum care instructions.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    120 views3 pages

    CP Partus Kasep

    Uploaded by

    Salman Faridzi
    This document summarizes a 4-day clinical pathway for a patient admitted with a diagnosis of cephalopelvic disproportion (CPD). It includes the patient's name, age, vital signs, diagnosis, treatment plan and activities during each day of admission. The patient received IV fluids, antibiotics, pain medications, mobilization and monitoring. Procedures included normal vaginal delivery assisted with vacuum extraction and suturing of perineal tears. The patient's condition stabilized with no infections or bleeding and she was discharged on the fourth day with nutrition and postpartum care instructions.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 3

    CLINICAL PATHWAYS

    RSUD KAB. SAMPANG, PROVINSI JAWATIMUR


    PARTUS KASEP

    Nama Pasien Umur : Berat Badan : Tinggi Badan : Nomor Rekam Medis :
    ……………………………….. ……………….. ………………… ……………….. ……………………
    Diagnosis Awal : PARTUS KASEP Kode ICD 10 : O 63.1 Rencana Rawat : 4 hari
    R. Rawat Tgl/Jam Masuk Tgl/Jam Keluar Lama Rwt Kelas Tarif/hr (Rp) Biaya (Rp)
    …………….. ………………. ……………… …………… …….. ……………… ………….
    Aktivitas Pelayanan
    Hari Rawat 1 Hari Rawat 2 Hari Rawat 3 Hari Rawat 4 Hari Rawat 5
    Hari Sakit :….. Hari Sakit :….. Hari Sakit :….. Hari Sakit :….. Hari Sakit :…..
    Diagnosis :
    • Penyakit Utama PARTUS KASEP
    • Penyakit Penyerta
    • …………………….. + / - + / - + / - + / -
    • …………………….. + / - + / - + / - + / -
    • …………………….. + / - + / - + / - + / -
    • Komplikasi
    • …………………….. + / - + / - + / - + / -
    • …………………….. + / - + / - + / - + / -
    • …………………….. + / - + / - + / - + / -
    Assessmen Klinis …………….
    • Pemeriksaan Dokter ……………..
    • Konsultasi
    • …………………….. + / - + / - + / - + / -
    • …………………….. + / - + / - + / - + / -
    • …………………….. + / - + / - + / - + / -
    Pemeriksaan penunjang ……………….
    • DL + / -
    • NST/ CTG + / -
    • Kimia Klinik
    GDA + / -
    BUN + / -
    SK + / -
    SGOT / SGPT + / -
    Albumin + / -
    • SE
    Na + / -
    K + / -
    • HbsAG + / -
    • Golongan darah + / -
    • ………………………. + / - + / - + / - + / -
    • ………………………. + / - + / - + / - + / -
    Tindakan Medis ………………
    Pengakhiran Kehamilan
    • Per Vaginam + / -
    • Per Abdomen + / -
    Pembiusan Umum
    • Injeksi + / -
    • Gas + / -
    Pembiusan Regional + / -
    • …………………………….. + / -
    Tindakan Keperawatan ……………..
    • Pemasangan Infus + / -
    • Pelepasan infus + / -
    • Pemasangan Kateter + / -
    • Pelepasan Kateter + / -
    • Partus normal bidan + / - + / -
    • Persalinan dengan penyulit + / - + / -
    • Placenta manual + / - + / -
    • jahit perineum tk.II + / - + / -

    • Jahit perineum tk.III/IV + / - + / -


    • Jahit portio + / - + / -
    • Kompresi bimanual + / - + / -
    • Pasang tampon + / - + / -
    • Tranfusi darah + / - + / -
    • Sceren + / - + / -
    • Rawat luka + / - + / -
    • ……………………… + / - + / - + / - + / -
    • …………………… + / - + / - + / - + / -
    Obat - Obatan : ………………
    IVFD
    • D5% NaCl………..cc/hr (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    • Rl 1000cc ( Loading) (……..) + / -
    • RL : D5, 2 : 3, 28 tpm (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    • D5% drip oksitosin……mg (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    ………tpm
    Profilaksis
    • Cefazolin 2 gr,iv (……..) + / -
    Duran te Op
    • Metronodazole 500mg inf (……..) + / -
    Post Op
    • Norages 3 x …….gr/hr, iv (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    • Metoclopamid 3 x …..amp/ (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    hr. Iv
    • Cefotaxime 3 x …..g/hr iv (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    • Metronidazole 3 x 500mg/ (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    hari infus
    Oral :
    • Asam Mefenamat 3 x … (……..) + / - (……..) + / -
    amp/ hr, iv
    • Metergin 3 x …….mg/hr (……..) + / - (……..) + / -
    • ……………………………. (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    • …………………………….. (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    Nutrisi ……………..
    • Puasa + / - + / -
    • Makan Biasa : (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    Kalori…….kkal/ hr
    Protein ……...g/hr
    • ……………………………….. (……..) + / - (……..) + / - (……..) + / - (……..) + / -
    Mobilisasi : ……………..
    Tirah baring, mika miki + / - + / - + / - + / -
    ………………………….. + / - + / - + / - + / -
    Hasil ( Outcome) : ……………..
    • TTV Stabil + / - + / - + / - + / -
    • Kesadaran composmentis + / - + / - + / - + / -
    • Perdarahan + / - + / - + / - + / -
    • Infeksi + / - + / - + / - + / -
    • …………………………….. + / - + / - + / - + / -
    Pendidikan/ Rencana ……………..
    Pemulangan :
    • Penjelasan tentang Per + / -
    jalanan penyakit dan
    Komplikasi
    • Pemenuhan nutrisi adeku + / -
    at di rumah
    • Penjelasan tentang tanda + / -
    Infeksi
    • …………………………….
    Varians : …………….. …………….. …………….. ……………..
    …………….. …………….. …………….. ……………..
    Jumlah Biaya ………………
    Perawat (PPJP) Diagnosis Akhir Kode
    Kode ICD 10 Jenis Tindakan
    ……………………….. ICD 9 -CM
    PPDU :…………….. • Utama Partus kasep O 63.1 • Pemasangan/Pelepasan Infus …………
    PPDS : ……………… • Penyerta …………………………… ………………… • …………………………………… …………
    Dokter …………………………… ………………… • …………………………………… …………
    Penanggung Jawab …………………………… ………………… • …………………………………… …………
    Pasien …………………………… ………………… • …………………………………… …………
    • Komplikasi …………………………… ………………… • …………………………………… …………
    …………………………… ………………… • …………………………………… …………
    …………………….. …………………………… ………………… • …………………………………… …………
    Verifikator : …………………………… ………………… • …………………………………… …………
    ……………………….. …………………………… ………………… • …………………………………… …………
    (....) Jumlah Pemakaian per hari

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