- ASSESSMENT
Day / date assessment: Sunday, November 20, 2011
- IDENTITY
Name of client: Mrs. S
Age: 25 years
Status: Married
Ethnicity: Java
Religion: Islam
Occupation: Housewife
Address: Tegal Arum
No.. RM: 512 219
- HISTORY OF NURSING
- 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.
- 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
|
- 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.
- Family health history
The client says there is no history of heart disease, high blood pressure and diabetes.
- Baby care plan is treated yourself.
- Ability and knowledge in caring for the baby:
- Breast Care
Clients said ASI has started out and will perform the breast care in order to breastfeed the child properly.
- Perineal care
Clients say the birth canal area cleaning routine especially when changing dressings. Clients say know how to clear the birth canal.
- Nutrition
Clients say that nutritious foods such as vegetables and fruits, as well as not doing buahann avoidance of certain foods unless prohibited by religion.
- Gymnastics puerperal
Clients say has never participated in gymnastics after pregnancy.
- Nurse
The client said it would give milk to their children. When asked for an example of how to breastfeed, the client shows the proper way.
- History KB:
Clients say the last injection before use KB in August 2010.
- Plans KB:
The client said it would use the KB as injecting client planned to have another child.
- Wedding History: The client has been married 1 time for 7 years.
- PHYSICAL EXAMINATION
General condition: composmentis
BP: 150/100 mm Hg Nadi: 96 x / min
RR: 20 x / min Temperature: 36 ° C
- Head and Neck
Inspection: There are no lesions on the head, hair distribution uniform, black hair, clean hair, eyes symmetrical, not anemic, not jaundiced sclera, symmetrical ears, does not have a hearing loss, nasal symmetry, there is no discharge, thrush (-), gum swelling (-), cavities (-), no visible enlargement of lymph nodes and thyroid.
Palpation: a bump on the head (-), enlarged lymph nodes and thyroid gland (-).
- Heart
Inspection: ICTUS cordis invisible.
Palpation: no terkaji
Percussion: not terkaji.
Auscultation: not terkaji
- Lungs - pulmonary
Inspection: maximum chest expansion, chest wall retraction (-)
Palpation: no terkaji
Percussion: not terkaji.
Auscultation: not terkaji
- Breast
Inspection: symmetrical shape, form prominent nipple, areola hyperpigmentation, colostrum is out
Palpation: Breast engorgement (-)
Date
|
H 1(20/11/2011)
|
Breast engorgement
|
There is no
|
ASI
|
Colostrum is out
|
Nipple
|
prominent
|
- Abdomen
Inspection: striae gravidarum (+), the linea nigra (+), no lesions.
Palpation:
Fundus uteri
|
H 1(20/11/2011)
|
High
|
2 fingers below the center
|
Position
|
Medial
|
Contraction
|
Strong
|
Consistency
|
Palpable hard
|
- Urogenitalia
Inspection: Hemorrhoids (-) Folley catheter Posted on November 19, 2011, perineum intact.
Day
|
H 1(20/11/2011)
|
Type lokea
|
Lokea rubra
|
Number
|
2x 167 cc dressing pads filled third part
|
Color
|
Fresh red
|
Consistency
|
C water
|
Odor
|
The stench of menstrual
|
- Extremity
H 1(20/11/2011)
| |
Akral
|
Cold
|
Edema
|
lower extremity +1 / +1
|
Capillary refill
|
<2 seconds
|
Varicose
|
-
|
How the signman
|
-
|
Hygiene
|
Nails short and clean
|
- BASIC NEEDS OF PATIENTS
- Activity
H 1
(20/11/2011)
| |
Mobilization
|
Leaning right and left, sit and walk.
|
Fulfillment ADL(Activity DailyLiving).
|
Able bathing, toileting, dressing, transferring, feeding, Continence
|
KATZ Index
|
A
|
- Nutrition and Fluids
- Nutrition
Before hospitalization
|
Hospitalization
H 1 (20/03/2011)
|
3 times a day with a varied menu of rice, side dishes and vegetablesand fruit.
|
NRG
|
- Fluid
BB = 61 kg after giving birth.
IWL = B x 15 = 61 x 15 = 38.125 cc / hour
24 24
IWL in 7 hours: 38.125 x 7 = 266.875 cc
Date / hour
|
Input
|
Output
|
Fluid balance
The input - output
|
H 1 (20/11/2011)
|
RL 420 cc
670 cc
|
733.875 cc
|
- 63.875 cc
|
- Elimination
BAK
|
CHAPTER
|
Before hospitalization:
in 1 day + 5-7 times
|
Before hospitalization:
Ny. N ordinary CHAPTER every day.Clients Last Chapter on 18 November 2011
|
When hospitalization:
H Clients using catheter catheter. The color yellow (+), hematuria (-).
|
When hospitalization:
H 1 Ny. CHAPTER N yet.
|
- Rest and sleep
The client says there is no problem with sleep patterns. ± 8 hours of sleep a long time. 6 hours a night and by day 2 hours. The client does not have any habits before bed.Clients say often wake up when the baby cries.
- Perception, sensory, cognitive
Said in a statement Clients feel pain in the birth canal. Clients say do not feel pain when the abdomen is pressed (SFH measurement).
- Provoktif (P): The client said the pain increased if the client moves.
- Palliative (P): The client says the pain is reduced if the client is resting (lying) in bed.
- Quality (Q): The client said the pain felt like sliced / sore.
- Region (R): The client said she felt pain in the birth canal
- Scale (S): The client said the pain was on a scale of 4 (scale 0-10)
- Time (T): The client said that sometimes feels pain (intermittent) and lasts ± 3 minutes
Cognitive: client says do not understand and are confused about the disease. The client said he was puzzled why the 10 days before giving birth sudden high blood pressure
- Stress and coping
- Maternal physiological changes
Clients said they were delighted with the birth of her second child. The client said he would take care of her son. The client said he wanted to have more children after this one.
- Bonding attachments
H 1 (20/11/2011) done with the baby close to the mother. Mothers clutching babies and begin breastfeeding.
- The concept of self-
- Body image: The client said he had no problem with her body and does not mention the body parts that are not favored.
- Role: He said that would take care of her own children and is ready to be a mother.
- Ideal self: Client says it will take care of the child with his family.
- Identity: Client as a woman.
- Personal Hygiene
Before hospitalization
|
Hospitalization
| |
H 1
(20/11/11)
| ||
Bath
|
2x a day
|
Disibin
|
Wash hair
|
client used to wash hair 2 days
|
-
|
- LABORATORY EXAMINATION RESULTS
Date 19 November 2011 at 16:01
Parameter
|
Result
|
Unit
|
The normal value
|
Information
|
WBC
|
14.6
|
[10 3 / uL]
|
5-10
|
H
|
RBC
|
3.9
|
[10 6 / uL]
|
4-5
| |
HGB
|
12.1
|
[G / dL]
|
12-16
| |
HCT
|
34
|
[%]
|
36.0 to 48.0
|
L
|
MCV
|
87
|
[Fl]
|
76.0 to 96.0
| |
MCH
|
31
|
[Pg]
|
27.0 to 32.0
| |
MCHC
|
36
|
[G / dL]
|
30.0 to 35.0
| |
PLT
|
2 00
|
[10 3 / uL]
|
150-450
| |
Neut%
|
81.60
|
[%]
|
50.0 to 70.0
|
H
|
Lymph osit%
|
11.30
|
[%]
|
25.0 to 40.0
|
L
|
Mono sit%
|
6.70
|
[%]
|
2.0 to 8.0
| |
Eosinophils%
|
0.20
|
[%]
|
2.0-4.0
|
L
|
Basophils%
|
0, 20
|
[%]
|
0.0 to 1.0
| |
Urea
|
1 0.7
|
mg%
|
<50
| |
Creatinine
|
0, 40
|
mg%
|
L <1.2, P <0.9
| |
SGOT
|
23.0
|
u / L
|
0-35
| |
SGPT
|
17.0
|
u / L
|
0-35
| |
BT
|
2
|
minute
|
1-3
| |
CT
|
4
|
minute
|
3-6
| |
Goals. Blood
|
B
| |||
HBsAg
|
negative
| |||
Urine
| ||||
Proteins
|
+2
|
- THERAPY
No..
|
Name of medication
|
Dose
|
Indication
|
Contraindications
|
Side effects
|
1.
|
Amoxicillin
|
3x500 mg
|
Respiratory tract infections, genito-urinary tract, skin and soft tissue caused by Gram-positive and-negative organisms were sensitive to this drug
|
Hypersensitivity to penicillin.Infectious mononucleosis
|
Hypersensitivity reactions, GI disturbances
|
2.
|
Mefenamic acid
|
3x500 mg
|
Headache, toothache, muscle pain bone pain due to injury, postoperative pain, pain after childbirth, disminore, rheumatic pain, spinal pain, fever.
|
Peptic ulcers, kidney damage, asthma is sensitive to ains.
|
Hematologic reactions and skin, GI disorders.
Gastrointestinal disturbances may occur, such as irritation of the stomach, intestinal colic, nausea, vomiting and diarrhea, drowsiness, dizziness, headache, blurred vision, vertigo, dyspepsia.
|
3.
|
Nifedipine
|
3x10 mg
|
Treatment of hypertension, treatment of coronary heart disease: chronic stable angina pectoris, post-infarction angina pectoris.
|
Hypersensitivity to nifedipine or class of dihydropyridine calcium channel diseases, cardiovascular shock, the provision in the first 8 days after acute myocardial infarction;pregnancy, lactation.
|
Transient and mild vasodilation, hypotension. Rarely, gastrointestinal reactions and skin. Very rare: temporary vision changes, chest discomfort, when it arises, treatment should be discontinued.
|
4.
|
Viliron
|
1x1 tablet
|
Drug haematinics and tonic
| ||
5.
|
MgSO 4
|
Loadingdose: 6 g in 500 ml of RL 20 drops per minute
|
Reducing the quantity of acetylcholine, relaxes muscles, lowers blood pressure, lowers the frequency and intensity of uterine contractions.
|
Contraindicated in pregnant clients who have myasthenia gravis, a history of heart disease and impaired kidney function.
|
Lethargy, muscle weakness, sweating, facial flushing and nasal congestion. Nausea and vomiting may occur, constipation, blurred vision, headaches and hoarseness.
|
II. DATA ANALYSIS
Initial client: Ny. S Status obstetrics: P 2 A 0
Age: 25 years Space: Edelweiss
No..
|
Date / day
|
Data focus
|
Nursing Diagnosis
|
Signed
|
1.
|
Sunday,
20/11/2011
Pkl. 09:30
|
DS:
Clients say the pain increases if the client moves.
Clients say the pain is reduced if the client breaks (lying) in bed.
Clients say the pain feels like sliced / sore.
The client said she felt pain in the birth canal.
Client has to Atakan pain was on a scale of 4 (scale 0-10).
Clients say sometimes feels pain (intermittent) and lasts ± 1 minute.
DO:
|
Acute pain associated with trauma to the birth canal
| |
2.
|
Sunday,
20/11/2011
Pkl. 09:30
|
DS:
Clients say do not complain of dizziness and stiff neck are not.
DO:
|
The risk of ineffective tissue perfusion: kidney associated with decreased organ function: vasospasm and increase in BP.
| |
3.
|
Sunday,
20/11/2011
Pkl. 09:30
|
DS:
DO: -
|
Lack of knowledge related to the limited exposure
| |
4.
|
Sunday, 11/20/2011
|
DS:
Clients say do not complain of dizziness and stiff neck are not.
DO:
|
The risk of seizures associated with a decrease in cerebral tissue perfusion
|
PRIORITY ISSUE:
- Acute pain associated with trauma to the birth canal.
- The risk of seizures associated with a decrease in cerebral tissue perfusion
- Rehearsal o Ineffective tissue perfusion: kidney associated with decreased organ function: vasospasm and increase in BP.
- Lack of knowledge associated with exposure limitations.
III. Nursing Plan
Initial client: Ny. S Status obstetrics: P 2 A 0
Age: 25 years Space: Edelweiss
No..
|
Nursing Diagnosis
|
Destination
|
NIC Code
|
Intervention
|
Signed
|
1.
|
Acute pain associated with. trauma of the birth canal
|
After nursing action for 2 x 24 hour client perceived pain decreased, with the result criteria:
|
1400
6680
2304
|
Pain Management
Vital Signs Monitoring
Medical Administration: Oral
| |
2.
|
The risk of seizures associated with a decrease in cerebral tissue perfusion
|
After nursing measures 3 x 24 hours the risk of seizures did not occur with the expected outcomes:
|
(Source: Nursing diagnosis, Lynda Carpenito Juall)
| ||
3.
|
The risk of ineffective tissue perfusion: kidney associated with decreased organ function: vasospasm and increase in BP
|
After nursing actions for 3 x 24 hours perfusion ineffective renal tissue does not occur, the outcome criteria:
|
4130
7610
6680
6482
2304
231 4
|
Fluid Monitoring
Bedside Laboratory Testing
Vital Signs Monitoring
Environmental Management: Comfort
Medical Administration: Oral
Medical Administration: Intravenous
| |
4.
|
Lack of knowledge of disease processes: severe preeclampsia associated with exposure limitations.
|
After treatment for 1 x 30 min increased client knowledge is characterized by:
|
5510
|
|
IV. IMPLEMENTATION
Initial client: Ny. S Status obstetrics: P 2 A 0
Age: 25 years Space: Edelweiss
Date
/ Time
|
No..Dx
|
Implementation
|
Summative Evaluation
|
T TD
|
20/11/11
Pkl. 09.3 0
09:35
10.0 0
10:00
12:00
12:05
12:30
13:30
|
1, 2,3
1
2, 3
2, 3
1,2, 3
1
1,2, 3
2, 3
|
Monitor the TTV
Menga teaches clients to use nonpharmacologic techniques: deep breathing relaxation techniques
Perform the action k olaborasi giving MgSO 4 to 6 grams in 500 ml of fluid RL 20 drops per minute
Restrict incoming visitors.
Monitor the TTV
Monitor the client's pain
Providing collaborative action: analgesic administration: 500 mg mefenamic acid and antihypertensive medication: 10 mg niphedipine
Monitor fluid intake and output clients
|
S: -.
O:
BP: 160/10 0 mmHg, N: 98 x / min, T: 36 0C, RR: 20 x / min.
S:
The client said it will use the breath in when going to change position to relieve pain
O:
Clients can perform deep breathing as exemplified by the nurse.
S: -
O:
There does not appear on the client signs the side effects of the drug.
S:
Family says it will enter the room alternately
O:
There are 2 people who meet with clients in the treatment room.
S:
The client said it felt better than ever.
O:
BP: 140/10 0 mmHg, N: 90 x / min, T: 36 0C, RR: 20 x / min.
S:
Clients say the pain in the street lahi r has been reduced to 3 scale. Clients say has done a deep breath when it started moving. Clients say deep breathing can reduce pain.
O:
Expression client looks relaxed
S: -
O:
There does not appear on the client signs the side effects of the drug.
S:
Clients say from morning already starfruitdrink ¾ cup of tea.
O:
Urine 300 cc.
|
V. EVALUATION
Initial client: Ny. S Status obstetrics: P 2 A 0
Age: 25 years Space: Edelweiss
Date / day
|
No. Dx.
|
Nursing Diagnosis
|
Evaluation
|
TTD
|
Sunday,
20/11/2011
Pkl. 14:00
|
1
|
Acute pain bd birth canal trauma
|
S:
Clients say the pain in the street lahi r has been reduced to 3 scale. Clients say has done a deep breath when it started moving. Clients say deep breathing can reduce pain.
O:
BP: 140/10 0 mmHg, N: 90 x / min, T: 36 0 C, RR: 20 x / min.Clients seemed relaxed. Clients are able to do deep breathing relaxation techniques.
A:
Partially solved the problem.
Has not been resolved:
Pain scale to 1
P:
Continue intervention.
Motivation clients to mobilize.
| |
Sunday,
20/11/2011
Pkl. 14:00
|
2
|
The risk of seizures associated with a decrease in cerebral tissue perfusion
|
S:
The client said it felt better than ever.
Clients say not feel shortness of breath
Clients say never had a seizure.
O:
Composmentis consciousness.
BP: 140/10 0 mmHg,
N: 90 x / min,
RR: 20 x / min.
Clients were in the HCU
Clients get 6 grams of MgSO4 therapy dissolved in 500 ml of RL 20 TPM
Clients get oxygen 3 liters / min (cannula)
A: The risk does not occur, the problem is not resolved
Blood pressure is not within normal limits
P:
Monitor blood pressure
Collaborative examination of urinary protein
| |
Sunday,
20/11/2011
Pkl. 14:00
|
3
|
The risk of ineffective tissue perfusion: bd kidney organ function decline: vasospasm and increase in BP.
|
S:
The client said it felt better than ever. Clients say not feel shortness of breath and never seizures. The client says it will take a given drug.
O:
Composmentis consciousness. TD: 140/100 mmHg, N: 90 x / min, T: 36 0 C, RR: 20 x / min. Clients taking drugs given. No allergic reactions such as nausea, vomiting, itching and redness.
A:
Partially solved the problem.
TD has not been within the normal range of 120/80 - 130/90 mmHg. Laboratory examination is not done anymore.
P:
Continue intervention.
Perform laboratory tests, especially for urea, creatinine and urine protein. Recommended for routine drugs and routine given control.
|
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