STIKES RS.

BAPTIS KEDIRI

UNDERGRADUATE NURSING STUDY PROGRAM

FORMAT FOR ASSESMENT OF MATERNITY NURSING CARE

(GYNOCOLOGICAL CASES)

STUDENT NAME : YESIMA AGUNG PASKAWATI

NIM : 01.2.16.00567

ROOM : INSTALLATION OUTPATIENT

Date of hospital admission : 25 june 2018

Medical record number : 524633

Incoming diagnosis : Uterine Myoma Subserosum Stemmed

Assessment date : 25 june 2018

Time : 11.30 o’clock

I. ASSESSMENT
A. Subjective data of IDENTIY (BIODATA)

a. Patient name : Mrs. E j. husband’s name : Mr. S

b. Age : 51 years old k. Age : 56 years old
c. Tribe/Nation : Java/Indonesian l. Tribe/Nation : Java/Indonesian
d. Religion : Islam m. Religion : Islam
e. Education : Graduated elementary n. Education : Graduated
school elementary school
f. Occupatio n : Housewife o. Occupatio n : Enterpreneur
g. Income :- p. Income :-
h. Office address :- q. Office address :-
i. Home address : Besuk Gurah Kab. Kediri r. Home address : Besuk Gurah Kab.
Kediri

II. CURRENT HEALTH STATUS

1. Chief Complaint
The patient said that he was afraid because tomorrow he would undergo surgery
2. The Reason for a Hospital Visit
 The patient is in control of an outpatient installation because the patient will
undergo surgery

Complaints arise : ( ) gradually ( √ ) sudden

III. NURSING HISTORY

1. Obstetric History
a. Menstrual History
Menarche : 14 years old
Menstruation before : 23 may 2018
Duration : ± 5 to 6 day
Amount : ± 3 cork/day
HPHT : 23 april 2018
Duration : ± 5 to 6 day
Amount : ± 3 cork/day
HPL/HTP :-
Cycle : The patient said that menstruation is not every
month, sometimes once every 2 months
Tidy/No : Irregular
Disminorhoe : patients often feel disminore every menstruation
Flour albus : yes, Amount: a little , color/smell: clen odorless
b. History of past childbirth` pregnancy:

Puerperal
Child Pregnancy childbirth complications child
Gestat
N ye ional compli help compli lacer infec blee P
o ars age cation type er cation ation tion ding sex BB J
 27 5
50 1
 20  32  nor  mid  m gra c
00 mount  - mal wife  -  -  -  - ale m m 

2. Family Planing History

Doing family planning : ( √ ) yes ( ) No
If yes what type of contraception has been or is being used:
 The patient says to take the hormonal KB which is the KB pill
3. Medical History
a. A disease a mother has experienced :
The patient said previously the patient had no history of serious illnesses that
had to be treated with medical care at this time the patient had a myoma.
b. Treatment obtained
The patient is currently taking medication from a doctor to deal with pain
c. Family history
(-) diabetes mellitus disease
(-) heart disease
(-) hypertension disease
(-) other diseases, mention : none
d. Environmental history
a) Hygiene :
The patient says the patient’s living environment is always clean
b) Danger :
The patient said there was no danger that threatned the environmental
around the place of residence such as factory waste pollution and others
c) Other Mention : none
e. Social aspects of piseco (Imogene M.King)
a) Self ideal :
The patient said he wanted to get well soon from his illness so that he
could carry out daily activities as usual without any disturbances
b) Self image :
The patient says he is a shy person and does not easily trust other people
he only wants to tell the problem only to people he trusts
c) Personal identity :
The patient said that he was a wife who tried to be the best for her
husband
d) Self regard :
The patient said she was worried whether or not she would accept her
condition after the opration or not, the patient was not confident
e) Self role :
 The patient said that he was worried whether or not the patient could
fulfill his obligations as a wife after surgery
f. Role function (Imogene M. King)
a) Decision-Making :
The patient and family decide to continue the opration so that the disease
does not get worse
b) Patient relationship with family :
The patient said that the family relationship was fine, no problem
c) Relationship with partner (husband) :
The patient said the relationship with the husband was fine no problem
d) Patient relationship with other patient :
The patient said to have a good relationship with other patients
e) Patient relationship with nurses and health workers :
The patient said that he had a good relationship with nurses and other
health professionals. The patient was very cooperative during the history
and asked many questions about the illness
f) The role of health consultation :
Nurses and doctors as well as midwives provide information about
patient’s illnesses, And also provide health services according to the needs
of patients
g) Type of help desired :
The patient wants immediate medical help without surgery because the
patient is afraid of surgery.
h) Spiritual role :
The patiet said that he always carried out his religious duties according to
his religion and beliefs namely the five daily prayers.
4. Special Basic Needs
a. Nutritional pattern
a) Frequency of eating : 3 time/day
b) Appetite : ( √ ) good ( ) no appetite, reason : -
c) Type of home food :
The patient said consuming foods such as fruit vegetables and side dishes
d) Unwanted food/allergic/abstinence : none
b. Elimination pattern
Urination
Frequency : 4 to 5 time/days
Color : clear yellow
Complaints when urinating : none
Defecate
Frequency : 1 to 2 time/days
Color : brownish yellow
Smell : normal
Consistency : soft
Complaints : none
c. Personal hygiene patterns
Bath
Frequency : 2 time/days
Soap : ( √ ) yes, ( ) no
Oral hygiene
Frequency : 2 time/days
Time : ( √ ) morning ( √ ) afternoon ( ) after aeting
Hair washing
Frequency : 2 days
Shampoo : ( √ ) yes ( ) no
d. Rest and sleep patterns
a) Sleep a long time : ± 5 to 6 hour/days. Afternoon : 1 hour, night: 5 hour
b) Habit before going to bed :
The patient says always pray before bedtime
c) Complaints :
Said when feeling pain the patient always wakes up from sleep
d) Working time : patients say morning to evening always do their job as a
housewife
e) Sports : ( ) yes ( √ ) no
The type : -
Frequency : -
f) Free time activities : rest and gather with family
 g) Complaints in activity : activity is hampered when pain arises suddenly
e. Habit patterns that affect health
a) Smok : no
b) Liquor : no
c) Drug dependence : no
5. Physical Examination
a. General state :
The patient looks weak, looks grin, holds the stomach, looks pale and sweeps
out compos mentis
b. Vital sign
Blood pressure : 120/90 mmHg pulse : 88 x/minute
Respiration : 22 x/minute temperature :-
Weight : 52 kg height : 155 cm
c. Head
a) Shape :
Noemal looking head shape there is no enlargement or bump on the head
b) Hair :
Black hair there is little gray hair looks clean no dandruff
c) Scalp :
No lesions on the scalp no tenderness
d) Complaints :
The patient said there were no complaints in the head area
d. Eye :
a) Eyelid : no visible edema of the palpebral looks concave
b) Conjunctiva : anemic conjungctiva
c) Sclera : white sclera does not have jaundice
d) Complaints : the patient said there were no complaints in the
eye area
e. Nose : nose looks clen and there are no polyps
a) Allergic reaction : there is no allergic reaction
b) Sine : there is no sine
c) Complaints : the patient said there were no complaints in the
nose area
 f. Ear : ears look clean
g. Mounth and throat
a) Oral cavity : mucosa appears dry with dental caries without
stomatitis
b) Tongue : tongue looks clean
c) Tonsils : there is no enlarged tonsils
d) Difficulty swallowing: the patient says he has no difficulty swallowing
h. Chest and axilla
a) Inspection : symmetrical breasts between right and left, there are no lumps
on the axilla
b) Palpation vocal vremitus : bilateral symmetrical vibrations decrease
downward (vibrations between right and left are the same
c) Percussion : sonor percussion sounds
d) Auscultation : no additional breath sounds
i. abdomen
a) inspection: visible lump in the abdomen
b) Auscultation: normal bowel sounds 8 to 12 times / minute
c) palpation: a lump in the abdomen felt hard
d) percussion: tympanic abdominal percussion sounds
j. genitourinary
a) perineum / vulva: the vulva appears clean
b) vesika urinaria: there is no buildup of urine in the bladder
k. integument
a) skin turgor: normal skin turgor <3 seconds
b) skin color: brown
c) difficulty in movement: experiencing difficulty in movement due to pain
d) others mention: capillary refil time (CRT): <2 seconds
l. extremities
a) right hand: no edema
b) left foot: no edema and varicose veins
c) right foot: no edema and varicose veins
6. supporting investigation
a. laboratory
 hb : 9 gr / dl
leukocytes : 9.03 10 ^ 3 / ul
neutrophil : 52.4%
lymphocytes : 37.5%
b. obtained therapy:
paracetamol 500 mg 3x1 po
plasminex 3x1 tablet po
vit B complex 3x1 tablet po

Kediri, 25 june 2018

college student

Yesima Agung Paskawati

 DATA ANALYSIS

PATIENT NAME : Mrs. E

AGE : 51 Years

REGISTER NUMBER : 524633

SUBJECTIVE DATA AND RELATED FACTORS / NURSING PROBLEMS

OBJECTIVE DATA RISKS (E) (NANDA)

Ds: the patient said that the Stress (Preoperative) Anxiety

patient was afraid because
tomorrow he would undergo
surgery

Do: the patient looks pale, the

patient looks sweat

Vital Sign :
S: -
P: 88 Times / Minute
N: 22 Times / Minute
Td: 120/80 Mmhg
 LIST OF NURSING DIAGNOSES

PATIENT NAME : Mrs. E

AGE : 51 Years

REGISTER NUMBER : 524633

NUMBE DATE NURSING DIAGNOSES DATE SIGNATURE

R APPEARED RESOLVED
1. 25 june 2018 Anxiety Associated With 25 june 2018
Stressors (Pre Operation)
Which Is Characterized
By:
: The Patient Said That
The Patient Feels Afraid
Because Tomorrow Will
Undergo Surgery
: Patient Looks Pale
: The Patient Looks
Sweat
:Vital Sign
S: -
P: 88 Times / Minute
N: 22 Times / Minute
Td: 120/80 Mmhg
 NURSING CARE PLAN

PATIENT NAME : Mrs. E

AGE : 51 Years

REGISTER NUMBER : 524633

Nursing Diagnoses: Anxiety Associated With Stressors (Preoperation)

1. NOC: Anxiety level……………………………………………….(Code 1211)

a. Restless Feelings………………..3…….. Maintained / Enhanced…….. 4
b. tense face………………………..3……..Maintained / Enhanced…….. 5
c. can't make a decision……………3……..Maintained / Enhanced…….. 4
d. panic attack……………………...3……. Maintained / Enhanced…….. 4
e. the fear conveyed orally…………3……. Maintained / Enhanced…….. 5
f. cold sweat………………………..3…….Maintained / Enhanced…….. 5
g. …………………………………………..Maintained / Enhanced………
h. …………………………………………..Maintained / Enhanced………
i. …………………………………………..Maintained / Enhanced………

2. NOC :………………………………………………………………..(Code:……)
a…………………………………………….Maintained / Enhanced………
b……………………………………….……Maintained / Enhanced………
c…………………………………………….Maintained / Enhanced………
d…………………………………………….Maintained / Enhanced………
 NURSING ACTIONS

PATIENT NAME : Mrs. E

AGE : 51 Years

REGISTER NUMBER : 524633

No No DX DATE / TIME NURSING ACTIONS SIGNATURE

1. I. 25 June 2018 Vital Sign

11.45 pm
S: -
P: 88 Times / Minute
N: 22 Times / Minute
Td: 120/80 Mmhg

conduct assessment of patient

12.00 pm
anxiety including anxiety,
anxiety level, verbal and non
verbal signs

teach patients and families

12.15 pm
relaxation techniques
 PROGRESS NOTE

PATIENT NAME : Mrs. E

AGE : 51 Years

THE DATE : 25 June 2018

No No. DX TIME EVALUATION

1. I. 13.00 pm S : The patient said that he was still
afraid because he would be operated
on
: Patients and families say they
understand the deep breathing
relaxation technique to reduce
anxiety
O : The patient looks sweaty
The patient looks pale
: Vital Sign
S: -
P: 88 Times / Minute
N: 22 Times / Minute
Td: 120/80 Mmhg

A: Anxiety problem has not been

resolved
P: intervention continues at home
(ONEC)