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Lembar Pemeriksaan Tanda-Tanda Vital Dan Kondisi Bayi: 28 Mei 2015 Jam HR (X/menit) RR (X/menit) T (C) Catatan

This document records the vital signs and condition of a baby over several days in May and June 2015. It includes the baby's heart rate, respiratory rate, temperature, and any notes at various times each day. The baby received treatments including oxygen supplementation, intravenous fluids and medications. Overall the baby's condition was stable with no complaints of shortness of breath, fever or seizures noted. The baby's vital signs, appearance and assessments remained largely unchanged over the monitoring period.

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Santy Phang
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25 views

Lembar Pemeriksaan Tanda-Tanda Vital Dan Kondisi Bayi: 28 Mei 2015 Jam HR (X/menit) RR (X/menit) T (C) Catatan

This document records the vital signs and condition of a baby over several days in May and June 2015. It includes the baby's heart rate, respiratory rate, temperature, and any notes at various times each day. The baby received treatments including oxygen supplementation, intravenous fluids and medications. Overall the baby's condition was stable with no complaints of shortness of breath, fever or seizures noted. The baby's vital signs, appearance and assessments remained largely unchanged over the monitoring period.

Uploaded by

Santy Phang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Lembar Pemeriksaan Tanda-Tanda Vital dan Kondisi Bayi

28 Mei 2015
HR
Jam
(x/menit
)
14.00
128
15.00
137
16.00
133
17.00
130
19.00
124
21.00
156
22.00
156
24.00
143
29 Mei 2015
Jam
HR
03.00
131
06.00
128
08.00
130
10.00
140
12.00
129
14.00
133
16.00
136
18.00
132
20.00
135
24.00
141
30 Mei 2015
Jam
HR
02.00
131
04.00
142
06.00
142
08.00
130
10.00
138
12.00
120
14.00
121
16.00
112
18.00
123
20.00
125
22.00
120
24.00
130
31 Mei 2015
Jam
HR
02.00
04.00
06.00
08.00
10.00
12.00
14.00
16.00
18.00
20.00
22.00
24.00
1 Juni 2015
Jam
HR
02.00
04.00

RR
(x/menit
)
48
51
57
56
46
56
56
52

T (0C)

Catatan

35,5
35,8
36,0
36,4
36,5
36,5
36,5
36,3

Dilakukan pemasangan infusvia umbilikal

RR
56
60
54
68
61
58
55
61
54
52

T
36,5
37,0
36,4
36,8
36,5
37,0
36,4
36,4
36,6
36,6

Catatan

RR
42
45
48
47
58
60
60
61
58
57
60
56

T
36,8
35,3
36,6
35,8
37,1
37,6
37,0
37,3
37,2
37,0
37,0
36,6

Catatan
Kejang (+) Inj.Phenobarbital 50mg
Pemasangan OGT residu warna kuning

RR

Catatan

RR

Catatan

Inj.Claneksi, Inj.

BAB(+)
Downes Score 2; rr >60,ret 1

Downes Score 2; rr >60

06.00
08.00
10.00
12.00
14.00
16.00
18.00
20.00
22.00
24.00
2 Juni
Jam
02.00
04.00
06.00
08.00
10.00
12.00
14.00
16.00
18.00
20.00
22.00
24.00
3 Juni
Jam
02.00
04.00
06.00
08.00
10.00
12.00
14.00
16.00
18.00
20.00
22.00
24.00
4 Juni
Jam
02.00
04.00
06.00
08.00
10.00
12.00
14.00
16.00
18.00
20.00
22.00
24.00
5 Juni
Jam
02.00
04.00
06.00
08.00

2015
HR

RR

Catatan

2015
HR

RR

Catatan

2015
HR

RR

Catatan

2015
HR

RR

Catatan

10.00
12.00
14.00
16.00
18.00
20.00
22.00
24.00

1.4
Tanggal

Follow Up Harian
Subjective

Objective

Assessment

Planning

Sesak napas (-),


demam (-), kejang (-)

Kesadaran:

HR: x/mnt T: 0C
RR: x/mnt
SaO2: %

CA -/- SI -/- pupil isokor


Cor: S1S2 tunggal, reguler,

murmur(-) gallop(-)
Pulmo: SND bronkovesikuler,
whe(-/-) rh(-/-)
Abd: distensi(-)BU(+)n, timpani,
hepar lien tidak teraba.
Eks: akral hangat, udem(-),
CRT<2det
Kulit: sianosis(-), ikterik(-),turgor
kulit baik.
Neurologik: refleks
Downes Score:
Kesadaran:
HR: x/mnt T: 0C
RR: x/mnt
SaO2: %
CA -/- SI -/- pupil isokor
Cor: S1S2 tunggal, reguler,
murmur(-) gallop(-)
Pulmo: SND bronkovesikuler,
whe(-/-) rh(-/-)
Abd: distensi(-)BU(+)n, timpani,
hepar lien tidak teraba.
Eks: akral hangat, udem(-),
CRT<2det
Kulit: sianosis(-), ikterik(-),turgor
kulit baik.
Kesadaran:
HR: x/mnt T: 0C
RR: x/mnt
SaO2: %
CA -/- SI -/- pupil isokor
Cor: S1S2 tunggal, reguler,
murmur(-) gallop(-)
Pulmo: SND bronkovesikuler,
whe(-/-) rh(-/-)
Abd: distensi(-)BU(+)n, timpani,
hepar lien tidak teraba.
Eks: akral hangat, udem(-),
CRT<2det
Kulit: sianosis(-), ikterik(-),turgor
kulit baik.
Kesadaran:
HR: x/mnt T: 0C
RR: x/mnt
SaO2: %
CA -/- SI -/- pupil isokor
Cor: S1S2 tunggal, reguler,
murmur(-) gallop(-)
Pulmo: SND bronkovesikuler,
whe(-/-) rh(-/-)
Abd: distensi(-)BU(+)n, timpani,
hepar lien tidak teraba.
Eks: akral hangat, udem(-),
CRT<2det
Kulit: sianosis(-), ikterik(-),turgor

Neonatus Cukup Bulan

(NCB)
Besar Masa Kehamilan

(BMK)

Hipoglikemia

O2
0,5
L/mnt
(meaning O2)
D10% 15 tts/mnt
Claneksi 2x250mg
Gentamicin
2x25mg
Minum ASI 1015cc/3jam
Intake
1520cc/3jam
Cek GDS

28 Mei 2015

Sesak napas (-),


demam (-), kejang (-)

29 Mei 2015

Sesak napas (-),


demam (-), kejang (-)

30 Mei 2015

31 Mei 2015

Sesak napas (-),


demam (-), kejang (-)

Sesak napas (-),


demam (-), kejang (-)

1 Juni 2015

Sesak napas (-),


demam (-), kejang (-)

2 Juni 2015

Sesak napas (-),


demam (-), kejang (-)

3 Juni 2015

Sesak napas (-),


demam (-), kejang (-)

4 Juni 2015

kulit baik.
Kesadaran:
HR: x/mnt T: 0C
RR: x/mnt
SaO2: %
CA -/- SI -/- pupil isokor
Cor: S1S2 tunggal, reguler,
murmur(-) gallop(-)
Pulmo: SND bronkovesikuler,
whe(-/-) rh(-/-)
Abd: distensi(-)BU(+)n, timpani,
hepar lien tidak teraba.
Eks: akral hangat, udem(-),
CRT<2det
Kulit: sianosis(-), ikterik(-),turgor
kulit baik.
Kesadaran:
HR: x/mnt T: 0C
RR: x/mnt
SaO2: %
CA -/- SI -/- pupil isokor
Cor: S1S2 tunggal, reguler,
murmur(-) gallop(-)
Pulmo: SND bronkovesikuler,
whe(-/-) rh(-/-)
Abd: distensi(-)BU(+)n, timpani,
hepar lien tidak teraba.
Eks: akral hangat, udem(-),
CRT<2det
Kulit: sianosis(-), ikterik(-),turgor
kulit baik.
Kesadaran:
HR: x/mnt T: 0C
RR: x/mnt
SaO2: %
CA -/- SI -/- pupil isokor
Cor: S1S2 tunggal, reguler,
murmur(-) gallop(-)
Pulmo: SND bronkovesikuler,
whe(-/-) rh(-/-)
Abd: distensi(-)BU(+)n, timpani,
hepar lien tidak teraba.
Eks: akral hangat, udem(-),
CRT<2det
Kulit: sianosis(-), ikterik(-),turgor
kulit baik.
Kesadaran:
HR: x/mnt T: 0C
RR: x/mnt
SaO2: %
CA -/- SI -/- pupil isokor
Cor: S1S2 tunggal, reguler,
murmur(-) gallop(-)
Pulmo: SND bronkovesikuler,
whe(-/-) rh(-/-)
Abd: distensi(-)BU(+)n, timpani,
hepar lien tidak teraba.
Eks: akral hangat, udem(-),
CRT<2det
Kulit: sianosis(-), ikterik(-),turgor
kulit baik.

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