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FOLLOW-UP POST OPERATION

July, 12th 2013 : The Operation started from 05.50 07.10 am At 19.00
S: O: feel a little pain in the incision of operation General conditon : Look mild sick Consciousness : Composmentis Blood Pressure : 110/70 mmHg Pulse : 88 x/minutes RR : 20 x/minutes Temp : 36,5 0C Eyes Extremities Mammae : Conjunctiva anemis -/Sclera icteric -/: capillary refill time <2 , oedema : Breast milk -/Retraction -/Mass -/Pain -/: Uterine fundal as high as the umbilicus, Look the verban after operation blood seep (-). Pus(-) : Supel, tenderness + in area after operation, contraction of uterus + : not done : Bowel sounds (+) 3 times/minutes (soft) : :Lochia Rubra Fluor : (-)

Abdomen Inpection Palpation Percussion Auscultation Genitalia

A : Post SCTP in Pregnancy of 38th weeks of gestation + Antiphospholipid Syndrome P : diet bertahap IVFD II RL I D5% 30 drops/mnt Medikamentosa : Biocepime 2x1 gr Alinamin F 2x1 gr (amp) Orasic 2x1 amp Tramal 3x1 Dulcolax 2x1 supp

July, 13th 2013 At 18.00 Post Op day 1 S: O: reduce pain in the incision of operation, flatus (+), defecation (-) General conditon : Look mild sick Consciousness : Composmentis Blood Pressure : 100/70 mmHg Pulse : 72 x/minutes RR : 20 x/minutes Temp : 36,3 0C Eyes Extremities Mammae : Conjunctiva anemis -/Sclera icteric -/: capillary refill time <2 , oedema : Breast milk +/+ (little) Retraction -/Mass -/Pain -/: Uterine fundal as high as the umbilicus, Look the verban after operation, blood seep (-), pus (-) : Supel, tenderness + in area after operation, contraction of uterus + : not done : Bowel sounds (+) 3 times/minutes (soft) : :Lochia Rubra Fluor : (-)

Abdomen Inpection Palpation Percussion Auscultation Genitalia

A : Post SCTP in Pregnancy of 38th weeks of gestation + Antiphospholipid Syndrome P : diet bertahap IVFD II RL I D5% 30 drops/mnt Medikamentosa : Biocepime 2x1 gr Alinamin F 2x1 gr (amp) Orasic 2x1 amp Tramal 3x1 Dulcolax 2x1 supp

July, 14th 2013 At 18.00 Post Op day 2 S: O: reduce pain in the incision of operation, flatus (+), defecation (+) General conditon : Look mild sick Consciousness : Composmentis Blood Pressure : 100/70 mmHg Pulse : 72 x/minutes RR : 20 x/minutes Temp : 36,3 0C Eyes Extremities Mammae : Conjunctiva anemis -/Sclera icteric -/: capillary refill time <2 , oedema : Breast milk +/+ (little) Retraction -/Mass -/Pain -/: Uterine fundal as high as the umbilicus, Look the verban after operation, blood seep (-), pus (-) : Supel, tenderness + in area after operation, contraction of uterus + : not done : Bowel sounds (+) 4 times/minutes (soft) : :Lochia Rubra Fluor : (-)

Abdomen Inpection Palpation Percussion Auscultation Genitalia

A : Post SCTP in Pregnancy of 38th weeks of gestation + Antiphospholipid Syndrome P : diet : Mild Medikamentosa : Biocepime 2x1 gr Alinamin F 2x1 gr (amp) Orasic 2x1 amp Tramal 3x1

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