Nursing care GINEKOLOGI

REVIEWERS AN

Date of Assessment               : February 11, 2013 09 .00 hours

1. CLIENT IDENTITY

Name of client               : Mrs. R

Age               : 72 year

Address               : Binangun, Wonosobo

Education               : S D

Job               : Farmers

Religion               : Islam

Tribe               : Java

Medical diagnosis               :

Name of Husband               : Mr.. Ngatno

2. HEALTH HISTORY
1. The main complaint

Clients say bleeding for 2 weeks in the birth canal.

2. Health history now

Clients come through Polyclinic Obstetrics and Gynecology Hospital JRT Setjonegoro on Saturday at 10. 00 pm because there was bleeding from the net birth. Clients also say feel the heat and stomach bloating, stomach looks great and sounds tinny. Patients want flatus but not so stomach feels bloated. Upon poly clients are encouraged to be hospitalized, and of poly clients to the delivery room for observation after 2 hours of observed client was transferred to the edelweiss. During the client assessment attached to intravenous fluid therapy and RL catheter.

3. Past medical history
1. Disease and treatment

The patient had been suffering from hepatitis before.

2. Allergy

Clients say so far do not have a good terha dap food allergies and medications.

3. Disease and previous surgery

Clients say 've never had surgery.

4. History hospitalized earlier

Clients said previously been treated in hospital mah ru ie in space Bougenvile Hospital JRT Setjonegoro

5. Accident or c Edera

Clients say t idak had a history of previous accidents or injuries.

6. Behavior b erisiko

1)         Lifestyle                                          : Simple

2)         Consumption of caffeine                  : No.

3)         Smoke                                           : No.

4)         Alcohol                                           : No.

5)         Drugs                                            : do not.

6)         Practice unsafe sex                        : do not.

7. History of violence / abuse

1)         Injuries due to violence               : does not exist.

2)         Experience raped                         : does not exist.

3)         The final result                        :   no RIW paragraph violence and persecution.

4. Family health history
1. Hereditary disease

Clients tell ua res RGA no client with a history of hereditary diseases such as sto u ng, hypertension, asthma, and diabetes mellitus.

2. Current disease in the family

Clients say no health problems that occur on the client's family at this time either from the client's family of the husband's family ma UPUN clients.

3. Riway at mental illness in the family: t here is no.

5. History g inekologi
1. Characteristics of menstruation: irregular menstrual Clients say every month, 28 day cycle, duration 5-7 days, dysmenorrhea (-), vaginal discharge (-).
2. Menarche: The client said menarche at the age of 1 2 years.
3. Last menstrual period: the client is not menstruating around the age of 45.
4. Experience menstruation: Clients say usually before and after menstruation clients never feel stomach pain
5. Bleeding middle of the cycle: Not the middle of the cycle bleeding.
6. Menopause: Clients already experienced menopa use.
7. Contraception: Since the client's third child melahirk clients using IUDs and the use of IUDs has been 20 years, never changed or controlled.
8. Age at first pregnancy: Clients say The first pregnancy she was 17 years old.
9. Sexually transmitted diseases: The client has never had a history of sexually transmitted diseases.
6. Obstetric history: P 3 A 0.
7. History p sikososial
1. Individual coping

1)         Self-awareness and self-esteem

Clients are aware of the situation himself who has the disease and undergoing treatment. The client said he would do anything and follow the recommended treatment by the hospital as long as the client can recover and not experience abdominal pain again.

2)         Picture of yourself

Clients realize they ri he is now 72 years old and the age of the client at the moment the client realizes that the client will not be able to have children again. Clients only hope in the age of the client's current client does not have a disease that could interfere with her ​​daily activities.

3)         Ideal self

Clients say clients want like other older women who are not sick.

4)         The role of self-

Clients as housewives and not work. Clients say never had sexual intercourse, due to the client's husband died three years since the lau.

5)         Management of stress

Clients say usually the client will tell everything to his son. A boy always gives her motivation and encouragement to clients to recover and undergo treatment.

2. Spiritual

K lien say if the home clients are always diligent prayer 5 times as long in the hospital but the client never pray because the condition does not allow. However clients are very eager to be able to run prayer hospital

8. Basic assessment
1. Neurosensori

General state of good clients, composmentis, good orientation, good eye contact, speak fluently regularly.

2. Nutrition and fluid

Clients said clients usually drink ± 3 cups each day. Clients say after ill always be careful in eating by always eating refined foods. According to the family since feeling pain in the abdomen and decreased appetite client a client last week who experience nausea and vomiting. Clients say if eating feels nausea and vomiting in addition to the said client spent a quarter hectare portion of the food provided by the hospital. Clients already 1 week did not eat rice.

Anthropometric

BB (before illness)               : 47 Kg

BB (after illness)               : 4 2 Kg

TB                                           : 15 4 cm

IMT   = Weight (kg) = 42      = 17.72 (underweight)

TB (m) ² (1.54) 2

Biochemistry

Hb = 6 mg / dl

Clinical

Client looks thin and weak, anemic conjunctiva.

Diet

Smooth Porridge

Ballance fluid

Date	Intake	Output
11/02	1. Drinking water: 6 00 cc 2. I nfuse RL: 3 00 cc 3. Food:   1 5 0 cc Total: 10 5 0 cc	1. Urine: 6 00 cc 2. IWL       : 183.75 cc 3. PPV: 25 0 cc 4. BAK: 100 cc Total       : 113 3.75 cc (-8 3.75 cc)

3. Personal hygiene

Clients say before admission usually clients shower 2 times a day, brush your teeth 2 times a day and wash 2 days. But as long as the client hospital only 1 bath times and usually more frequently wiped with cold water. Personal hygiene may be assisted by family clients. Clients look clean.

4. Activity and exercise

Clients said before ill clients are still able to do chores such as sweeping, washing, cooking. But after the pain he mengur angi activity because it does not stand the pain in his stomach.

5. Elimination

The client says there is no problem with his bladder. BAK clients frequently, usually> 5 times / day, clear yellow color, characteristic odor. Diving treated CHAPTER clients using a catheter. CHAPTER client 1 times a day.

6. Breathing

Clients say never experienced shortness of breath.

7. Security / mobilization

Perception / coordination (visual, auditory, and sensory unfavorable due process of degeneration). Daily activities carried out by independent and minimal assistance by the family.

8. Sleep and rest

Clients say clients sleep patterns did not change before and after in the hospital. Clients iasanya b ± 7 hours sleep a day.

9. Comfort

Clients say pain in the lower abdomen. Assessment of pain:

Palliative               : Increased pain when moving or sitting

Provocative               : Reduced pain when lying down

Quality                             : Pain as a squeezing

Region                             : In the left lower abdomen

Scale                             : Pain scale client 7 of 10

Time                             : At any time

10. Patterns of sexual

The client had not had sexual intercourse since her husband died clients 3 years ago.

11. Knowledge

Clients say not understand the disease process and the client feel anxious with a penyakitny and often asked how long he would be hospitalized.

3. PHYSICAL EXAMINATION

1. The general state              

1. Awareness               : Composmentis
2.      TTV               :               TD 1 3 0/9 0 mmHg, N 92 x / min, s uhu 3 7 5 0 C, RR 18 x / min.
3. BB               : 4 2 kg               TB: 15 4 cm              

2. Head: Shape mesocephal, black hair and gray hair already there, clean, uniform distribution, there are no bumps or lesions.
3. Eyes: Symmetrical, not sclera jaundice, conjunctival pallor.
4. Nose: Clean, no accumulation of secretions, no septal deviation.
5. Mouth: Clean, dry mucous lips, teeth no cavities, looks pale.
6. Ear: Clean, no wax.
7. Neck: There is no tenderness, no enlargement of the thyroid gland, tid ak no jugular venous distention.
8. Heart:

Inspection               : IC does not appear.

Palpation               : IC palpable in SIC V.

Percussion               : Pekak.

Auscultation               : BJ pure 1-2, tid a k no gallop, no murmurs.

9. Lungs:

Inspection               :               Chest symmetrical, symmetrical chest expansion, no retractions of the chest wall.

Palpation               : Tactile fremituas right = left.

Percussion               : Sonor.

Auscultation               : Sound vesicular breath, wheezing or ronkhi no.

10. Breast: Symmetrical, no lumps.
11. Abdomen

Inspection               : convex

Auscultation               : Bowel 9 x / min.

Palpas i               :               Tenderness in the left part of the abdomen UNDER b.

Percussion               : Dulness

12. Extremities

Above               :               RL infusion mounted to the right of 20 TPM, dry skin turgor, capillary refill <2 seconds.

Under               : No e dem a, no varices.

13. Examination of urogenital

Kebersiha n               : Clients say no itching, clean.

Spending: The client said extravasation's already berkura ng than 2 weeks ago a number of 250 cc, with quality fresh red blood.

14. Rectum / anus: No ad a hemorrhoidal

4. Investigations

Laboratory Studies

Date               : February 9, 2013

Hemoglobin (L)	6	g / dl	11.7 - 15.5
Leukocyte	10.9	10 3 / ul	3.6 to 11.0
Eusinofil (L)	1.4	%	2.00 to 4.00
Basophils	0, 3	%	0-1
Neutrophils (H)	81.5	%	50-70
Lymphocytes (L)	9.2	%	25-40
Monocytes	7.6	%	2-8
Hematocrit (L)	18	%	35-47
Erythrocytes (L)	2.2	10 6 / ML	3.8 to 5.20
Platelets	334	10 3 ML	150-400
MCV	84	TL	80-100
MCH	28	Pg	26-34
MCHC	33	g / dl	32-36
BT	3, 00	Minute	1-3
CT	4, 0 0	Minute	3-6
Blood group	A
Hb SAg	Positive

E. The results of the ultrasound examination

Results U SG

Date: 9 201 February 3

Results: mass seemed eystik 7.49 cm x 6.74 cm

Impression: kistoma ovary

5. MEDICAL THERAPY
1.      Infusion RL `               20 TPM
2.      Cefotaxime               2x1 g
3.      Kalnex               3x500 mg

DATA ANALYSIS

Name of client: Mrs. R               Age: 72 years               Space: Edelweiss

No.	Date, Hour	Data Focus	Diagnosis Kep	Signed
1.	11 201 February 3 at 09:00	DS: -    Clients say it has been 2 weeks of bleeding in the birth canal -    Clients say drinking only 3 glasses DO: -    BC: -83, 75 cc -    Ht: 18% (low) -    Dry skin turgor -    Hb: 6 mg / dl -       TTV: TD 130/90 mmHg, N 92 x / min, temperature of 3 7 5 0C, RR 18 x / min	Risk of fluid volume deficiency bd active fluid volume loss	Blessing
2.	11 201 February 3 hour 09:10	DS: -       Clients say right pain in the abdomen -       Assessment of pain: Palliative: increased pain when moving or sitting Provocative: reduced pain when lying down Quality: pain as a squeezing Region: in the left lower abdomen Scale: client pain scale 7 of 10 Time: any time DO: -       Clients seemed to wince in pain, clutching his stomach when switching position to stand up from a seated position -       The results of ultrasound (+) ovarian kistoma -       In the abdominal examination there is tenderness to palpation in the left lower abdomen	N yeri bd disease process (suppression / compression) tissue in the organ chamber abdominal	Blessing
3.	11 201 February 3 hour 09:15	DS: -   Clients say after ill always be careful in eating by always eating refined foods. -   According to the family since feeling pain in the abdomen and decreased appetite client a client last week who experience nausea and vomiting. -   Clients say if eating feels nausea and vomiting in addition to the client's mengatak just spent ¼ servings of food provided by the hospital. -   Clients already 1 week did not eat rice DO: -    Clients do not spend their food -    Clients face pale -    Conjunctival pallor -    Assessment of nutrition: A: BMI = 17.72 (underweight) B: Hb = 6 mg / dl C: thin & weak client D: diet soft	Imbalance nutrition less than body requirements, inadequate intake bd	Blessing

PRIORITY ISSUE

1.   Risk of fluid volume deficiency bd active fluid volume loss

2. N yeri bd disease process (suppression / compression) j aringan on abdominal organ chamber.

3. Imbalance nutrition less than body requirements, inadequate intake bd

Nursing Plan

Name of client: Mrs. R               Age: 72 years               Space: Edelweiss

Date, Hour	No Dx	Goals and Criteria Results	Intervention	Signed
11/2/1 3 09:40	1	After nursing actions for 3x 24 hour fluid volume deficiency does not occur with k riteria results: -        The client had no bleeding -        Clients can drink 8 glasses / day -        Ht in the normal range (35-47%) -        Client does not dry skin -        Ballance balance (input = output) -       Vital signs within normal limits (TD: 110/70-120/80 mmHg, HR: 60-100x/menit, RR: 16-24x/menit, T = 36-37,5 0 C) -       Hb in the normal range (11.7 to 15.5 mg / dl)	Monitor vital signs Monitor discharge (bleeding urine, IWL) Monitor signs of fluid imbalance (mucous membranes, skin turgor, changes in pulse rate, body temperature, Capilary refill, blood pressure) Motivation clients meet the oral fluid intake (at least 1500 cc per day) Monitor fluid ballance Collaboration: Give intravenous fluid therapy: RL 20 TPM Monitor Hb value clients. Give transfusion PRC / WB to normal Hb clients.	Blessing
11/2/1 3 09:30	2	After nursing actions for 3x24 hours clients are expected to decrease pain with the expected outcomes: -       Clients expressed reduced pain -       Pain scale drops to 5-6 -       Facial expressions clients relax	Determine history of pain (location, frequency, duration and intensity)   Monitor response to verbal and non-verbal clients related pain   Provide basic comfort measures and relaxation and entertainment activities Increase helped refocus perhatia   Encourage the use of pain management skills (relaxation techniques, visualization, guided imagery)   Evaluation of pain relief 5	Blessing
11/2/1 3 09:35	3	After nursing actions during the 24-hour 3x clients overcome nutritional deficiencies with k riteria results: -        Clients can spend more servings eat and can eat rice -        Clients can say nausea and vomiting reduced -        Hb clients in the normal range (11.7 to 15.5 mg / dl) -        The conjunctiva was not anemic -        Not face pale	Monitor food intake every day Measure BB every day / as indicated Encourage the client to eat foods high in calories, rich in nutrients Create a pleasant dining atmosphere Identification of nausea, vomiting, anorexia Push to eat little but often Collaboration: Check laboratory (Hb)	Blessing

IV. IMPLEMENTATION

Initial client               : Ny. R              

Age               : 45 years               Space               : Edelweiss

Day / Date	Dx	Hour	Implementation	Client response	Signed
Monday, 2/11/13	1.	09.3 0 09:35 09:45 09:55	Monitor vital signs Monitor for signs of fluid imbalance (mucous membranes, skin turgor, changes in pulse rate, body temperature, Capilary refill) Motivating clients meet the oral fluid intake (at least 1500 cc per day) Giving transfusion PRC / WB to normal Hb clients	S: - O: BP 130/90 mmHg, N 92 x / min, temperature of 3 7 5 0 C, RR 18 x / min S: client says there is still bleeding O: dry mucous membranes, temperature of 37.5 0 C, strong pulse, dry skin turgor S: Client says will be a lot of drinking as recommended O: client and family cooperative S: - O: Transfusion entry 1 kolf	Blessing
	2 3.	10:00 10. 0 5 11:00 12:00 12:10 12:15	Men entukan history of pain (location, frequency, duration and intensity) Mem antau verbal and non-verbal responses related to client pain Mend orong pain management skills ie use breath in Monitor food intake every day Mend orong client to eat foods high in calories, rich in nutrients and recommends to eat little but often Identifying the presence of nausea, vomiting, anorexia	S: -       K lie n say pain in the left lower abdomen -       Assessment of pain: Palliative: increased pain when moving or sitting Provocative: reduced pain when lying down Quality: pain as a squeezing Region: in the left lower abdomen Scale: client pain scale 7 of 10 Time: any time O: open-plan with the client and client's current complaint S: Clients sometimes say pain is felt O: k lien appears to localize nyeritika will switch positions S: client says it will try when you're pain O: client cooperative and listened to nurses S: clients say only eat ¼ servings O: clients do not spend on food from the hospital S: client says it will follow the advice O: cooperative clients S: clients say every meal was always vomiting O: client looks weak	Blessing
Tuesday, 12/02/13	1	09:30 09:35 09:45 09:55	Monitor vital signs Monitor for signs of fluid imbalance (mucous membranes, skin turgor, changes in pulse rate, body temperature, Capilary refill) Motivating clients meet the oral fluid intake (at least 1500 cc per day) Giving transfusion PRC / WB to normal Hb clients	S: - O: BP 130/70 mmHg, N 86 x / min, temperature of 3 7 0 C, RR 20 x / min S: client says there is still bleeding O: dry mucous membranes, a temperature of 37 0 C, strong pulse, dry skin turgor S: Client says will be a lot of drinking as recommended O: client and family cooperative S: - O: Transfusion entry 1 kolf	Blessing
	2 3	10:00 10:05 11:00 12:00	Men entukan history of pain (location, frequency, duration and intensity) Mem antau verbal and non-verbal responses related to client pain Mend orong pain management skills ie use breath in Identifying the presence of nausea, vomiting, anorexia	S: Clients say pain in the left lower abdomen still feels like yesterday Assessment of pain Palliative: when moving or sitting Provocative: reduced pain when lying down Quality: pain as a squeezing Region: in the left lower abdomen Scale: client pain scale 7 of 10 Time: any time O: client and family cooperative S: Clients sometimes say pain is felt O: client appears to localize pain when going to switch positions S: client says it will try when you're pain O: client cooperative and listened to nurses S: Why does the client nausea Takan today 3 times   O: client looks weak	Blessing
Wednesday, 13/02/13	2 2 1 1 3	08:30 09:00 09:35 13:00 13:30	Assessing back pain perceived by the client Guiding deep breathing relaxation techniques Monitor the value of Hb Monitor vital signs and signs of lack of fluids Men gevaluasi vomiting and oral intake on the client	S: Client d i say pain lower left abdomen but it still feels less Assessment of pain Palliative: when moving or sitting Provocative: reduced pain when lying down Quality: pain as a squeezing Region: in the left lower abdomen Scale: 6 clients a pain scale of 10 Time: any time O: client and family cooperative S: the client said it conducted a deep breath O: clients follow the advice S: - O: Hb = 13.2 mg / dl S: - O: m ukosa membranes moist, denyu t strong pulse, moist skin turgor BP: 120/9 0 mmHg HR: 8 6 x / mnt RR: 20x/mnt T: 36.5 0 C S: client says it does not throw up and try to eat little but often O: clients spend more servings	Blessing

V. EVALUATION

Initial client               : Ny. R                                                                               

Age               : 72 years                                               Space: Edelweiss

Day / Date	No..Dx	Evaluation	Signed
Wednesday, 13/02/13 Wednesday, 2/13/13	1	S: -    The client says there is no bleeding -    Clients say drinking 5 glasses already O: -    BC: input = 1450 output: 11, 83, 75 cc (BC: +266.25 cc) -    Ht: 18% (low) -    Clammy skin turgor, moist mucous lips -    Hb: 13.2 mg / dl -    TTV: BP: 120/9 0 mmHg HR: 8 6 x / mnt RR: 20x/mnt T: 36.5 0 C A: the problem is not resolved Q: continue intervention monitor the input and output of fluids to fluid balance ballance monitor signs of lack of fluids	Blessing
	2	S: Clients say pain in the left lower abdomen still feels but is reduced Assessment of pain Palliative: when moving or sitting Provocative: reduced pain when lying down Quality: pain as a squeezing Region: in the left lower abdomen Scale: 6 clients a pain scale of 10 Time: any time O: client seemed quieter than before A: the problem has been resolved Q: continue intervention:     Monitor pain verbal and non-verbal Motivation techniques to reduce pain deep breath	Blessing
Wednesday, 2/13/13	3.	S: -   According to the client's family appetite has increased compared to the previous -   Clients say spend ½ servings of food provided by the hospital. -   Client said applying to eat little but often O: -    Clients spend their food servings -    Not face pale -    The conjunctiva was not anemic A: the problem has been resolved Q: continue intervention Monitor nutritional intake Motivation enhancement eating	Blessing