Maternity Nursing Care

1. ASSESSMENT

Day / date assessment: Sunday, November 20, 2011

1. IDENTITY

Name of client: Mrs. S

Age: 25 years

Status: Married

Ethnicity: Java

Religion: Islam

Occupation: Housewife

Address: Tegal Arum

No.. RM: 512 219

2. HISTORY OF NURSING

1. History of childbirth

Clients come to the hospital emergency room KRT Setjonegoro Wonosobo 15.55 hours with captions term pregnancies with PEB. The client is then sent into space VK. Monitoring in the space VK showed that fundus height 31 cm, single fetus, elongated layout, cephalic presentation, palpable 4/5 parts, v / u is quiet, smooth vaginal walls, thick lower portion, and the opening of the amniotic fluid + 5 cm. Clients feel kenceng-kenceng blood and mucus out at 13:00.

17.30 rupture, clear colored. 17:45 hours the baby is born spontaneously with male gender, infant weight 3000 g, length 46 cm with Apgar score of 7/9. This was followed by kelhiran placenta weighing ± 500 grams, size 19x19x2 cm, the impression of a complete, long cord ± 50 cm and there are three blood vessels.

Monitoring blood pressure continued to clients. Clients were observed in the VK then transferred to the HCU Clients Edelweiss at 10:00 am with composmentis consciousness, supine position, installed drip infusion RL 6gram MgSO 4 40% 20 TPM, Folley catheter and O 2 3 lpm nasal cannula.

2. Obstetrics Status: Ruling days - 1 P 2 A 0

No..	Type of delivery	JK	BB birth	Year of birth	The state of the baby at birth	Age at this time
1.	Spontaneous labor	♀	30 00 g	2005	Healthy	6 years

3. Pregnancy problems now:

Clients perform routine antenatal care at health centers and midwives during pregnancy as much as 6 times. History of hypertension, heart disease, kidney, hepatitis, asthma, and diabetes refuted by the client. On 9 November 2011 the client feel swollen legs, then checked himself into health center clients. Test results show clients increased blood pressure and proteinuria +3. During pregnancy the client is experiencing dizziness and nausea in the first trimester but never experienced blurred vision and headache.

4. Family health history

The client says there is no history of heart disease, high blood pressure and diabetes.

Nursing Care in Stroke with Non Hemorrhagic

  

A.      IDENTITY PATIENT

Name                     : Ny. S

Address                 : Bhayangkara Purwodadi RT 04 RW 09

Age                       : 70 Years

Sex / status             : Women / widows

Job                         : Retired civil servant

Number of children                       : 5 people; 3 men, 2 women

Number of grandchildren              : 10 people

Sign RS                                         : July 13, 2005

B.       MEDICAL HISTORY PHYSICAL EVALUATION

I.         Medical History

1.     The main complaint of patients

Family / guardian says "eat drink still difficult, ngobrok, over the rest should be helped"

2.     History of surgery / operation

Never before

3.     History of hospitalization at Hospital

Has been Had lodgings in RS Yakkum Purwodadi, because hypertension and asthma

4.     Other medical history

Already less than 5 years suffer from diabetes, HT

5.      History of allergy

There is no

6.    Habit

Families say the client had never smoked, drank alcohol, exercise participate in gymnastics elderly elderly neighborhood health, eating 3 meals a day, do not like to drink coffee

7.     The drugs currently

With a doctor's prescription

Ceftriaxon               1 x 2 g

Metronidazole               3 x 500 mg

Diflucan                             1 x 300 mg (PO)

Euterax                             1 x 25 mg (morning on an empty stomach)

Actrapid                             4 - 4-4

Na Cl                             3 x 100 mg

Plet oral                             1 x 100 mg

Asetosal                             1 x 100 mg

Without a prescription

Ø        Catheter care

Ø        Treatment of genital and perineal area

Ø        Oral hygiene

Ø        Maintenance infusion

8.      Summary symptoms

a.        Assessment of patients over their own health

         Not to be assessed subjectively

b.       Summary of typical symptoms

         There is a weakness, dysphagia

9.     Screening for depression

Can not be assessed

10.     Functional status

a.        Basic and instrumental ADL

       Bathing, ambulation, dressing, dressing, bladder / bowel movement, eating and drinking, drugs set to be "completely dependent on others" Patients ngobrok, BAK with Douwer tool cateter

b.       Functional limitations

       Before the illness, the client still can work like a mild way to the bathroom, ADL and others. But since the pain to unconsciousness, the client was just lying in bed.

Maternity Nursing with Spontaneous Parturition

I.          ASSESSMENT

Assessment done on December 31, 2011, At 13:30 pm in the delivery room.

A.       IDENTITY

Name of client: Mrs. E Name of husband: Mr.. S

Age: 24tahun Age: 27 years

Tribe: Tribe Java: Java

Religion: Islam Religion: Islam

Education: High School Education: High School

Occupation: IRT Occupation: Private

Address: Bara, Wonosobo Address: Bara, Wonosobo

B.       HISTORY OF NURSING

a.         Disease History Now

Clients come to the hospital emergency room KRT SETJONEGORO on December 31, 2011 at 8:20 pm with a description of G ₄ P ₂ A ₁ above referral information midwife with premature rupture of membranes (membranes has seeped since December 31, 2011 at 03.00). The client is a multigravida with preterm pregnancy 35 weeks 1 day. Kenceng-kenceng have not yet felt the blood mucus out, clear permeable membranes. The results of the examination in the ER showed composmentis client, not anemic, BP 140/90 mmHg and pulse 90 x / min. Clients enter the space VK 08.30 and the results of vital signs are: BP: 130/90 mmHg, HR: 96x / min, RR: 20x / min, temperature: 36.7⁰ C and palpation of the abdomen with the following results: fetus single, elongated, presenting the head, the head is palpable 4/5 parts, palpable left backs, TFU 28 cm, no fetal movement and FHR 152 x / min. Clients do not have edema in both lower extremities. The results of the examination: vaginal wall smooth, thick soft cervix, the opening of 1 cm, blood mucus has not come out, the membranes have ruptured, amniotic fluid out, clear color.

b.        Obstetric History

No.	Type of delivery	JK	BB birth	Year of birth	The state of the baby at birth	Age at this time
1.	Spontaneous	♀	2800 g	2005	healthy	Died at the age of 7 months
2.	Spontaneous	♀	3200 g	2007	healthy	4 years
3.	Curettage	-	-	2009	Abortion
4.	This Pregnant

c.         History of Gynecology

Menstrual history

a.         Menarche at age 1 4 years

b.        Regular cycles 30 days, the length + 8 days.

c.         Menstrual complaints: disminore (-)

d.        Complaints smelling vaginal discharge (-)

e.         HPHT   :   Clients say the increment a menstrual ter a khir is 2-5 - 201 1.

f.         HPL   :   HPL beradasarkan Naegel calculation rules is 9-2-2012.

d.        Antenatal Care: Clients say b erkunjung to midwife regularly every month and have received TT as much as 2 times. Clients say p ergerakan perceived fetal gestational age less than 5 months.

e.         Plan baby care: the baby will be taken care of itself.

f.         Ability and knowledge in caring for infants are:

g.        The client said it plans to breastfeed for 6 months to their children. Clients also said that already know about how to bathe the baby and cord care, because pregnancy is currently the third child for the client.

h.        History of family planning: Clients say before undergoing injections planning program.

i.          Ren cana KB: The client does not yet have a plan KB.

j.          D ahulu disease history: Client says that he does not have a history of heart disease, asthma, diabetes and high blood pressure.

k.        Previous pregnancy issues: abortion in the third pregnancy.

l.          Pregnancy problems now:

Clients say for pregnant clients complain waist pain, nausea and vomiting in early pregnancy, but this time no nausea and vomiting, back pain only and pain during contractions.Clients say that feeling anxious about the pregnancy at this time, because the first child died, and in the second pregnancy experienced a miscarriage in pregnancy to three

P enyakit family history: his client denies there is a history of heart disease, asthma, high blood pressure and diabetes.

Report Introduction Elderly Care Nursing With Clients Cognitive Disorders: Dementia

1.        DEFINITIONS

Dementia is a clinical syndrome that includes hilagnya intellectual function and memory so that causes dysfunction of daily living (Brocklehurst and Allen, 1987)

According Lumbantobing SM (1997), dementia is defined as intellectual deteriorasikapasitas caused by brain disease

2.        Etiology

Causes of dementia has been made ​​a "mnemonics" as follows:

D: drugs (pharmaceuticals) for example: sedative, anti-convulsive penenangm, anti-depressants, and anti-hypertensive

E:   emosional (emotional distress, such as depression)

M:  metabolic and endocrine eg: diabetes, kidney disorders, liver, thyroid, and electrolyte

N:     nutrisioral, eg: lack of vitamin B1, B6, B12 and folic acid

E:     eye and ear (eye and ear dysfunction), for example: cataracts, conductive deafness

T:     tumors and head trauma

I:      infection, Mass: encephalitis, tuberculosis, and neurosyphilis

A: arteriosklerotik (complications of atherosclerotic disease, Mass infarkmiokard, heart failure, etc.)

Urinary Tract Infection (UTI)

A.      Definition

Urinary Tract Infection (UTI) or urinary tract Infection (UTI) is a condition infasi presence of microorganisms in the urinary tract. (Agus Tessy, 2001)

Urinary Tract Infection (UTI) is a bacterial infection on the state of the urinary tract. (Enggram, Barbara, 1998)

B.       Classification

Urinary Tract Infection types, among others:

1.         Bladder (cystitis)

2.         urethra (urethritis)

3.         prostate (prostatitis)

4.         kidneys (pyelonephritis)

Urinary Tract Infection (UTI) in the elderly, can be divided into:

1.         UTI uncomplicated (simple)

       Simple UTI that occurs in patients with urinary tract is not good, normal anatomic and functional. UTI is the usi further, especially regarding women and people with infections only about superficial bladder mucosa.

2.         Complicated UTI

       Often cause a lot of problems because they are often difficult to eradicate germs, germs are often resistant to multiple kinds of antibiotics, frequent bacteremia, sepsis and shock. The UTI occurs when the circumstances are as follows:

a.         Abnormal urinary tract abnormalities, such as stones, urethral obstruction vesico reflex, bladder atony, paraplegia, permanent bladder catheter and prostatitis.

b.        Abnormalities of renal physiology: ARF and CRF.

c.         Impaired immune system

d.        Infections caused by virulent organisms just as urease-producing prosteus spp.

Nursing Care of Client A Main Problem with VIOLENT BEHAVIOR

A.                ASSESSMENT

1.                  The identity of the patient

a.                   Name: An. A

b.                  Age: 13 years

c.                   Gender: male

d.                  Address: Starch

e.                   Occupation: Student

f.                   Education: -

g.                  Medical Diagnosis: Schizophrenia Not Listed

Identity Penaggung replied:

a.                   Name: Ny. S

b.                  Age: 35 years

h.                  Address: Starch

c.                   Occupation: -

d.                  Relationship: Mother

Ward: XII (Madrim)

Log Date: March 13, 2012

Assessment dated: March 14, 2012

2.                  Reason entered (March 13, 2012)

Approximately 4 days before admission to hospital rampage beating up his client. Clients also have always said rude. When given pocket money, the client always use the money to buy cigarettes. The cigarette clients share with friends naughty. In addition, the client also denied the love of their parents. Clients also obsessed with becoming like those punk kids television d.

3.                  Now the Main Complaint (March 14, 2012)

Clients say annoyed. When irritated clients such as hearing voices that told him to hit people, so that the client forgot his own. Clients agitated, confused, like screaming.

4.                  Predisposing factors and precipitation

a.                   Factors predisposing

Clients have never been sick like this. Clients say since his father died 4 years old. Since that time the client was always scolded by her mother and the client is always blamed. Clients say because it is always blamed, he likes being naughty and ditching.

MK: Low Self-Esteem

b.                  Factors precipitation

A few days before entering the hospital said he had clients dipalak by classmates. Feeling irritated, client rampage and beat his friends.

MK: Behavioral Risk violence

                                                

5.                  Physical Assessment

a.                   Vital signs

BP: 110/70 mmHg

HR: 84 x / min

RR: 20 x / min

Temperature: 36 ^° C

b.                  Size:

TB: cm

BB: kg

c.                   's. A complain of shortness of breath after every smoke and heart palpitations.

d.                  Physical examination (head to toe):

Head: Short hair, black color, looks clean,

Eyes: The conjunctiva was not anemic, not jaundiced sclera.

Nose: Clean, symmetrical right and left, there was no injury and discharge from the nose.

Mouth: Clean and no injury.

Thorax: Development of symmetrical chest ka = ki, palpation: symmetrical chest expansion ka = ki, percussion: resonant and breath sounds vesicular

Heart: ICTUS cordis invisible, S1 and S2 sound pure.

Abdomen: There is no tenderness and no period

Genetalia: Not terkaji

Upper extremities: There is no weakness. Muscle strength: 5/5 and 5/5, Capilary refill = <2 seconds.

Lower extremities: There is no weakness. Muscle strength: 5/5 and 5/5, Capilary refill = <2 seconds.

Integument: No lesion anywhere, skin turgor <2 seconds and clammy skin.