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
|
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.
a.
Psychosocial history
Perceptions of pregnancy
and childbirth: Ny. E said that the pregnancy is highly anticipated family
and Ny. E and his family are expecting the birth of the first child to be
born normal and healthy. Clients are concerned about the state of the
current pregnancy because pregnancy had miscarried in the third, and the first
child died.
A.
PHYSICAL EXAMINATION
December 31, 2011 at 11:30 pm
The general state of
good mother Awareness: Composmentis,
BP: 130/90 mmHg Pulse:
96 x / min
RR: 20 x / min
Temperature: 36.7 0 C
1.
Anthropometric
BB before pregnancy: 54 kg TB: 154 cm
Pelvimetry: not terkaji.
LILA: 28 cm.
BMI: 54 = 22.78 (normal)
(1.54) 2
2.
Head and Neck
Inspection: There are no
lesions on the head, hair distribution uniform, black hair, straight, clean
hair, not anemic conjunctiva, sclera jaundice not, symmetrical ears, no wax
expenditure of ear, nose symmetrical, no spending excessive secretions from the
nose, mucosa moist lips, no canker sores, gum is not swollen, no tooth
cavities, not visible enlargement of lymph nodes and thyroid.
Palpation: No bump on
the head, there is no enlargement of the gland and thyroid gland linfe.
3.
Breast
Inspection: symmetrical
shape, protruding nipples, diareola hyperpigmentation, breast milk has not come
out.
Palpation: Breast
palpable taut.
4.
Heart
Inspection: ICTUS cordis
invisible.
Palpation: Not terkaji.
Percussion: Not terkaji.
Auscultation: BJ I-II
pure.
5.
Lungs - pulmonary
Inspection: maximum
chest expansion, no retractions of the chest wall.
Palpation: Not terkaji.
Percussion: Not terkaji.
Auscultation: Vesicular,
no additional breath sounds.
6.
Abdomen
Inspection: striae
gravidarum (+), the linea nigra (-), no lesions, no incision or scar tissue.
Palpation:
1.
LEOPOLD
I : Fundus t eraba round and soft
2.
LEOPOLD
II : Palpable left backs
3.
LEOPOLD
III : Divergent and b agian head already in PAP
4.
LEOPOLD
IV : K epala palpable 4/5 parts.
5.
Age pregnancy m ilan
calculated from LMP: 35 weeks + 1 day
6.
Fundus height 28 cm
7.
TBJ Johnson
formula: (28 -11) x155 = 2635 gram
8.
Contraction :
Strong, 2-3 x / min, with a duration of 25-35 "
9.
Auscultation: DJJ (+) =
1 52 x / min.
7.
Urogenitalia
Inspection: No
hemorrhoids
Examination in: Vulvar
quiet urethra, the vaginal wall smooth, thick soft cervix, the opening of 3 cm,
cephalic presentation, the membranes have ruptured, blood mucus (+), amniotic
fluid (+) clear, cephalic presentation.
8.
Extremities: There are
no edema, and varicose veins homan signs in the lower extremities and upper.
D.
BASIC NEEDS ASSESSMENT
|
During the treatment
|
|
|
Activity and Rest
|
Clients say while undergoing
treatment at the hospital just to be in bed because of back pain and told
clients more comfortable sleeping position.
|
|
Ego Integrity
|
Clients say they want to give
birth and look forward smoothly and the birth of healthy babies born and
survived.
|
|
Elimination
|
The client said during the
hospital did BAK independently.Not terkaji amount of urine output client, the
client said it to the bathroom as much as once, BAK around
500cc. Clients say during hospital visits yet CHAPTER.
|
|
Food and Fluids
|
Clients say during hospital have
eaten food from the hospital, discharged ¾ servings. Clients drank
approximately 500 cc.
|
|
Pain and Discomfort
|
Kien said start at 11.30, the
client felt abdominal pain and continuous pain felt ..
Assessment of pain:
Provocative = Clients say growing
pains when straining and trying to suppress the birth canal.
Palliative = Not terkaji.
Q = Clients say pain like kneaded.
R = Pain in the abdomen, and
spread quickly to the backbone and tail bone ..
S = scale 6 of 10.
T = Pain comes when a client
meneran, 2-3 times in 10 minutes with a duration of 25-35 ".
|
|
Security
|
Clients say for hospital activity
conducted on the bed and never fall, because the beds in the hospital were
given a safety.
|
|
Counseling and Learning
|
Clients say while undergoing
treatment at the hospital taught ways to reduce pain before labor and pushing
a good way
|
E.
EXAMINATION PENUNJAN G
Ultrasound (31/12/2011): enlarged uterus, single
fetus, fetal heart rate (+), Motion fetus (+), presentation of the head, back
left, TBJ 1666 ± 250 g, the placenta does not cover OUI, no calcification in
the placenta, water amniotic bit.
F.
THERAPY
|
Indication
|
Contra indications
|
Side Effects
|
|
|
Mefenamic acid 3x500mg / oral
|
Moderate to mild pain
|
Gastrointestinal ulceration,
gastrointestinal imflamasi and chronic hypersensitivity to mefenamic acid.
|
Drowsiness, dizziness, anxiety,
headache, visual disturbances, nausea, vomiting, bloating, diarrhea and skin
rash
|
|
Oxytocin
1 unit / ml im
|
Induction or stimulation of labor,
incomplete abortion, overcoming postpartum uterine bleeding.
|
Severe hypertension, vascular
disease, kidney damage and liver function, pregnancy and induction persalian.
|
Disporporsi cephalic, abnormal
fetal position, fetal distress, hypertonic uterus.
|
|
Methergin
1ml im
|
Actively overcome stage 3
persalian, uterine atony, subinfulsi treatment and puerperal bleeding.
|
Pregnancy, when 1 and stage 2
persalian, hypotension, pre-eclampsia and eclampsia.
|
Headache, abdominal pain,
hypertension
|
|
3x500mg amoxicillin / oral
|
Urogenital infections, skin and
soft tissue.
|
Hipersensitiv against penicillin
|
Nausea, stomach discomfort,
vomiting, bloating, vertigo, hearing damage.
|
|
Sulfa Ferosa
1x1 tablet
|
Anemia due to bleeding, lactation
|
Severe renal dysfunction.
|
Salauran gastrointestinal
disorders.
|
G.
LABOR REPORT
1.
INITIAL ASSESSMENT
a. Date: December 31 2011 at 13.3 0 hrs
b. Vital signs:
BP: 130/90 mmHg Pulse: 96 x / min
RR: 20 x / min Temperature: 36.7 0 C
c. Examination of the abdomen
Inspection: striae gravidarum (+), the linea
nigra (-), no lesions, no incision or scar tissue.
Palpation:
1.
Leopold
I : Fundus palpable round and soft
2.
Leopold
II : Palpable left backs
3.
Leopold
III : Divergent and the head has entered the LAP
4.
Leopold
IV : Head palpable fifth
5.
Gestational age
calculated from LMP: 35 weeks 1 day
6.
Fundus height: 28 cm
7.
TBJ Johnson formula:
(28-11) x155 = 2635 grams
8.
Contraction :
Strong, 2-3 x / min, with a duration of 25-35 "
9.
Auscultation: DJJ (+) =
138 x / min.
d. Examination in:
Vulva urethra quiet, slippery vaginal wall,
cervix thick, full opening, presentation of the head, blood mucus and amniotic
fluid was out.
e. Preparation perineum :
Disinfection with povidone iodine
f. Spending vaginal : L endir
blood
g. Vaginal bleeding : None.
h. Fetal
Status : Fetal life, single, pressed entasi
kep style.
2.
STAGE OF LABOR
STAGE I
a.
Starting delivery:
Ny. E says felt kenceng-kenceng from 31 December 2011 at 1 1.3 0 hrs
blood and mucus out.
b.
Signs and symptoms:
Dated December 31, 2011, said clients have felt
kenceng-kenceng frequently and on a regular basis since 11:30 pm. Amniotic
fluid and blood mucus felt was out.
Observation of the first stage is done by
midwives room, re-examination performed by a midwife at 11.30, which is 4 hours
after the initial examination (08:30). The results of the examination:
head presentation, vulva urethra quiet, slippery vaginal wall, cervix thick
soft opening of 3 cm, the amniotic fluid (+), Slime blood (+).
On December 31, 2011 at 13:50 client moved into
space gynecology, and checked in, and the results obtained in the examination
form 8 cms, and made preparations parturition set near the client, as well
as, preparing drugs: oxytocin 10 units, and prepare the baby resuscitation
equipment.
On December 31, 2011 at 13:55 in re-examination,
and the results obtained complete opening and start leading the delivery.
STAGE II
1.
Starting on December 31,
2011 at 13:50 pm.
2.
Long second stage: 10
minutes (At 13.5 5 - 14:05 pm)
3.
Signs and symptoms: 4-5
x stronger contractions in 10 minutes, 30-35 ", mucus blood (+), membranes
(+), a full 10 cm cervical dilation.
4.
Efforts meneran: Labor
led by midwives, midwives k spleen following orders, when his client came
meneran. Clients meneran the dorsal recumbent position with the hand holding
the thigh, the head flexion moment posi meneran, meneran client in accordance
with the command and the efforts made approximately 3 meneran -5 x in
time 10 minutes and the baby was born successfully. Date December 31, 2011
at 14:05 spontaneous vaginal birth, female gender, BB 18 00 gr, PB 50 cm.
5.
Psychosocial
circumstances: Clients continue to breath in before me neran. Clients seem
tense expression.
6.
Fluid therapy: Asering
RL 20 TPM.
7.
Birth records
Babies born spontaneously dated December 31,
2011 at 14:05 pm.
APGAR Score 7 at 1 minute. APGAR Score 9 at 5
minutes.
|
0
|
1
|
2
|
1 '
|
5 '
|
|
|
The frequency of heart
|
There is no
|
<100
|
> 100
|
2
|
2
|
|
Enterprises breath
|
There is no
|
Slow
|
Crying strong
|
2
|
2
|
|
Muscle tone
|
Paralyzed
|
Limb flexion slightly
|
Active Movement
|
1
|
1
|
|
Reflex
|
Not react
|
Little movement
|
Reaction against
|
1
|
2
|
|
Skin color
|
Blue / white
|
Body reddish, blue extremities
|
Redness
|
1
|
2
|
|
Total
|
7
|
9
|
Episiotomy is not done and there is no rupture
of the perineum.
Bonding mother and baby: Mothers say yet
relieved when the baby is born.
STAGE III
1.
Signs and
Symptoms : The fetus is born, the umbilical cord looked out of
the vagina.
2.
Delivery of the
placenta : December 31, 2011 P u k ul 14:05 to 14:10 (5
minutes).
3.
TTV :
BP: 120/70 mmHg, pulse: 112 x / min, RR: 2 4 x / min
4.
How birth
placenta : Spontaneous.
5.
Placental
Characteristics :
a. Size : 15 x 15 x 2 cm 3
b.
Weight :
40 0 grams
c. The length of the umbilical
cord : 50 cm
d.
Insertion :
Parasentralis
e. Blood vessel : 3 (2 arteries
and 1 vein)
f. Abnormality : There is no
exploration of the uterine cavity abnormalities and complete impression.
6.
Bleeding :
± 20 0 cc, characteristics of fresh red.
7.
Episiotomy
stitches : Do not do an episiotomy.
8.
Keadaa n
psychosocial : The client said he was thirsty and
tired. Clients seemed relieved, calmer expression.
9.
Management:
Immediately after birth, injected 10 units of
oxytocin. Dialkukan controlled cord stretching. Infusion of RL 20
TPM. Methergin 1ml im.
BABY
Spontaneous born December 31, 2011 at 14:05 pm.
Male gender - male.
Apgar Value: 7/9
Length: 41 cm
Weight 1800 grams
Anus: Perforated
Umbilical cord care: wrapped in sterile gauze.
Eye care: not treated specially.
Coil cord: no.
GDS: 73
Injection of Vit. K (+) / IM
There is caput succadenum in
infants Ny. E, but because Mrs E preterm infants and should undergo
further treatment in space perinatalogi.
STAGE IV
At the start date of December 31, 2011 at 14:15 to 16:15 pm (2
hours)
1.
Vital Signs: TD 12 0/7 0
g MMH Temperature 36.5 o C
: Nadi: 84 x / min RR: 24 x / min
2.
The state of the uterus:
TFU 1 fingers above the umbilicus
Therapy: The infusion of RL 20 TPM and metergyn 1 ml / IM because
TFU 1jari uterine contractions at the center and not robust.
Oral therapy: Amoxicilin 3x500 mg.
3x500 mg mefenamic acid
1x1 Ferosa sulfa tablets
3.
Mother and infant
bonding: Mother saw the baby from the bed and said relieved, and happy baby was
born, but still worried about the state of the baby.
Fluid balance during
labor
|
Input
|
Output
|
Fluid balance
7 Hours
|
|
|
December 31, 2011
pk. 13:30 to 19:30 pm
|
a.
infusion
of RL 20 TPM
RL: 700 cc
b.
Eating:
- cc
c.
Drink: 200 cc
+
900 cc
|
a.
BAK -
cc
b.
PPV 5
0 0 cc
c.
IWL: 236
cc +
736cc
|
+ 164 cc
|
Assessment of pain:
P: Pain and pain is reduced when moving the
break.
Q: street born stinging pain like the pain.
R: Pain is only felt around the birth canal.
S: Scale 5 of 10
Q: Pain is intermittent with a duration of about
2-5 minutes.
I.DATA
ANALYSIS
|
Date / Time
|
Data Focus
|
Dx. Kep.
|
Initials
|
|
|
1.
|
DS:
The client said he was worried
if something happens to the fetus if born now.
DO:
·
K lien
seemed concerned, several times changing the position from supine to the left
lateral position.
·
TD 13
0/90 mmHg pulse 90x/menit
·
RR
24x/menit temperature of 37.5 o
·
Examination
in: vulva urethra quiet, slippery vaginal wall, cervix thick, soft landscape,
3 cm cervical dilatation.
·
His 2-3
cm/25-3 5 "in 10 minutes, strong.
|
Anxiety bd situational crisis
|
Intention
|
|
|
2.
|
D S:
Clients say belly
kence kenceng-ng, pain, pegel at the waist and lower abdomen and want to
push.
Q: growing pains when his
Q: Client says pain like
pressure and squeezed.
R: pain in the abdominal
area, radiating to the spine, and waist
S: 6 out of 10 pain scale
Q: each his appearing, 2-3 times
in 10 minutes, 25-35 ", strong.
DO
·
TD 13
0/90mmHg RR 24 x / min
·
Nadi
92x/menit
·
DJJ
148x/menit,
·
His 2-3
x / 25-35 detik/10menit, strong
·
VT = 3
cm cervical dilation, H1 cephalic presentation, cervical
soft thick
·
Clients
seemed calm between contractions
|
Pain (acute) related to uterine
contractions and the opening of the birth canal
|
||
|
DS:
Clients say under water seeping
from 31/12/2011 03.00
DO:
Temperature of 37.5 0 C,
in the Examination: The amniotic membrane has ruptured, vulva, urethra quiet,
cervix thick, soft horizontal and 1 cm cervical dilation, blood and mucus.
vaginal expenditure: clear
amniotic fluid
|
Risk of infection
bdtin GGI port de entree: amniotic membrane rupture
|
|||
|
3.
|
DS
Clients say not stand it anymore,
and pain. Clients say they want to push.
P: not terkaji
Q: not terkaji
R: not terkaji
S: not terkaji
Q: not terkaji
DO
Cervical ilatasi D 10
cm, crowing, anus, prominent.
His 3-4x/40-45 "/ 10
minutes
FHR 142 x / min
TD 120/90 mmHg
|
Bd painful mechanical pressure on
the presentation
|
Intention
|
|
|
4.
|
DS = Clients ask when the seam is
finished
DO = rupture perinium degree II.
Exploration of the uterine cavity
incomplete impression
-Characteristics of the placenta
(19x19x2 cm 3), cord length 50cm, 3 pieces of blood
vessels (2 arteries, 1 vein)
|
High risk of injury bd maternal
placental separation difficulties.
|
Intention
|
II.PRIORITY
Nursing Diagnosis
STAGE I
1.
Anxiety associated
deng's situational crisis
2.
Pain (acute) related to
uterine contractions and the opening of the birth canal
3.
High risk of infection
associated with the port de entree: amniotic membrane rupture.
STAGE II
4.
Pain associated with
mechanical pressure on the presentation.
STAGE III AND IV
5.
High risk of injury
associated with maternal placental separation.
III.Nursing
Plan
|
Nursing Diagnosis
|
Goals and Criteria Results
|
Intervention
|
|
|
1
|
Anxiety bd situational crisis
|
After nursing actions for 1x30
minutes, maternal anxiety is reduced or lost with the expected outcomes:
a.
Clients
looking cool
b.
Client cooperative
action to care
c.
Client can
accept his own conditions
|
1.
Assess
the client's level of anxiety
2.
Facilitate
the client in identifying the causes of anxiety
3.
Explain
the process of childbirth
4.
Ti
ngkatkan clients effective coping mechanisms
5.
Encourage
families assisting clients in preparation for labor
|
|
2
|
Pain (acute) related to uterine
contractions and the opening of the birth canal
|
After nursing measures 1x30
minutes, the mother can adapt to pain outcome criteria:
a.
Client reduced
pain states.
b.
Clients
seemed to relax.
c.
Client able
to demonstrate the technique correctly when the breath in his.
|
1.
Assess
the patient's level of pain intensity
2.
Explain
the causes n yeri client
3.
Teach
mother to breath in anticipation of pain arises when his
4.
Teach
deep breathing to reduce pain
5.
Do a
back massage to reduce pain
|
|
3
|
There is a high risk of infection
bd port de entree: amniotic membrane rupture.
|
After nursing actions within 1 x 6
hours, not actual risk of infection with the expected outcomes:
a.
DJJ
within the normal range 120-160 x / min
b.
Clear
membranes. There is no change in color or odor.
c.
Body
temperature in the range of 36.5 to 37.5 client o C
|
1.
Monitor
client TTV 4 hours
2.
Observation
of amniotic expenditure, observe for color output and odor.
3.
Signs
Monitor - Client f n vital signs, especially temperature.
4.
Collaboration:
Giving amphi cillin 500 mg
|
|
4
|
Bd painful mechanical pressure on
the presentation
|
After nursing actions for 1 x 1
hour client will use the appropriate techniques to adapt to the pain, the
result criteria:
Clients are able to do meneran
well, the baby can be born less than 1 hour when phase 2.
|
1.
Encourage
clients to push with his current appears, and not falter.
2.
Monitor
the perineal and rectal protrusion, opening the mouth of the vagina and the
fetus.
3.
Encourage
clients to perform a dorsal recumbent position while straining.
4.
Assess
bladder fullness. Catheterization between visible distention and
contraction when the client is not able to avoid.
5.
Collaboration:
oxytocin immediately after birth, and methergin after delivery of the
placenta.
|
|
5
|
High risk of injury bd maternal
placental separation difficulties.
|
After nursing actions, within 1 x
24 hours, maternal injury does not occur with the expected outcomes:
a.
Client's
vital signs within normal range systolic BP ≤ 140/90 mm Hg and ≤ 90 mm Hg
diastolic
Temperature ≤ 38 ° C
Nadi 60-100 x / min
RR 18-24 x / min.
b.
Bleeding
within the normal range (≤ 500 cc vaginal)
c.
The
results of the uterine cavity exploration showed no placental.
|
1.
Palpation
of the fundus and massase slowly after the expulsion of the placenta
2.
Assess
the respiratory rhythm and development
3.
Clean
the vulva and perineum with warm water, give the pads.
4.
Monitor
for signs - vital signs
|
IV. IMPLEMENTATION
AND EVALUATION
|
Date
|
Implementation
|
Evaluation
|
Initials
|
|
|
31/12/2011
|
Confirm booking aji anxiety
level clients
Mendam Pingi clients in
identifying the causes of anxiety
Sed elaskan labor
Menga family njurkan
assisting clients in preparation for childbirth
|
S = Clients say palpitations
and anxiety due to the current labor've miscarriage and there are also
children who died as infants clients, but once explained, clients feel more
calm, though not relieved, because the unborn child. The client said he
wanted a quick delivery.
O = client honestly express
anxiety, clients understand expressions and understand the process of labor
that will be undertaken by the client, family accompany clients to date
before delivery.
A = the issue is resolved.
P = accompany clients in
labor, motivation execution relaxation to reduce anxiety clients.
|
Intention
|
|
|
2.
|
31/12/2011
|
confirm booking aji patient's
pain intensity level
Sed elaskan cause pain client
Menga mother taught
anticipate pain with deep breathing when his incurred
Menga taught deep breathing
to reduce pain
Mel akukan back massage to
reduce pain
|
S = Clients say slightly
reduced pain after a deep breath and massage on the back, P: pain at His
appearing, Q: like pressed and kneaded, R: abdomen, waist, S: 4 of 10, T: 3-4
x/10 minutes, with a duration of 30-40 ", strong.
O = BP 130/90 mm Hg, pulse
96 x / minute, his x/10menit 3-4, with a duration of 30-40 ", strong,
FHR 142 x / min, the client can perform deep breathing correctly, the client
appears to be more relaxed, back massage is done, the client is more relaxed
A = problem solved
P = lead delivery, prepare
the baby resuscitation
|
Intention
|
|
3.
|
31/12/2011
|
Monitor client TTV 4 hours
Observation of amniotic
expenditure, observe for color output and odor.
Monitor the client's vital
signs, especially temperature.
Collaboration: the
amphicillin 500 mg
|
S = The client said that the
amniotic fluid had seeped from 03.00, colored clear water seepage, no smell.
O = amniotic membrane
rupture, amniotic fluid is clear, no smell, blood and mucus out there, BP
130/90 mm Hg, pulse 96 x / minute, temperature 37.5 0 C,
the drug entered, the client does not have allergies.
A = problem solved
P = lead delivery, prepare
the baby resuscitation
|
Intention
|
|
4.
|
31/12/2011
|
Encourage clients to push with his
current appears, and not falter.
Monitor the perineal and rectal
protrusion, opening the mouth of the vagina and the fetus.
Encourage clients to perform a
dorsal recumbent position while straining.
|
S = The client asked when he could
start pushing, the client says it does not want to hold the push.
O = anus prominent, crowning, soft
and palpable bladder is full. Clients pushing the dorsal recumbent
position, the client can perform meneran properly according to the
instructions of midwives during the second stage of the process.
A = problem solved
P = provide 10 units of
oxytocin, controlled cord stretching
|
Intention
|
|
5.
|
31/12/2011
|
Collaboration: oxytocin
immediately after birth, and methergin after delivery of the placenta.
Palpation of the fundus and
massase slowly after the expulsion of the placenta
Clean the vulva and perineum
withwarm water, give the pads.
Monitor for signs - vital signs
|
S = Clients say relieved finally
been completed.
O = massage fundus and palpating
continue dila kukan, bleeding ± 200 cc, complete placenta ± 400gr, the
client has been cleared, the client applied bandage parturition, oxytocin
given after the baby is born, the placenta after birth methergin given.
A = problem solved
P = doing the monitoring
stage IV over 2 hours
|
Intention
|
Table IV Kala monitoring
|
TFU
|
Contraction
|
Action
|
TD
|
Pulse
|
Temperature
|
Bleeding
|
Urine
|
|
|
14:30
|
1 fingers above the umbilicus
|
Strong
|
Massage fundus
|
120/90 mmHg
|
100x/menit
|
Not
|
Not
|
-
|
|
14:45
|
1 fingers above the umbilicus
|
Strong
|
Massage fundus
|
Not
|
Not
|
Not
|
Not
|
-
|
|
15:00
|
Parallel umbilicus
|
Strong
|
Massage fundus
|
120/80 mmHg
|
98x / min
|
36.9 o C
|
Not
|
-
|
|
15.15
|
Not
|
Not
|
-
|
Not
|
Not terkaji
|
Not
|
Not
|
-
|
|
15:45
|
Parallel umbilicus
|
Strong
|
Massage fundus
|
120/80 mmHg
|
96x / min
|
36.9 o C
|
Clients changing pads, rather full
|
-
|
|
16:15
|
1 finger below the umbilicus
|
Strong
|
Massage fundus
|
Not terkaji
|
Not terkaji
|
Not
|
Not
|
-
|
No comments:
Post a Comment