TUGAS

BAHASA INGGRIS

Disusun Oleh :
Nama: camelya marlissa

Kelas: A

NPM: 12114201180117

Fakultas: kesehatan
Prodi: keperawatan

UNIVERSITAS KRISTEN INDONESIA MALUKU

2020
KASUS

Ny. K.O datang Puskesmas Oesapa dengan keluhan nyeri di perut bagian bawah dengan durasi 5
menit, selain itu tujuannya juga agar diberikan edukasi tentang teknik menyusui dan KB. Selain
itu diberikan juga edukasi tentang imunisasi. Hasil pemeriksaan didapatkan TD : 110/80, N:
82×/menit, S: 36,5ᵒC dengan skala nyeri 3, serta hasil Lab HB : 93 g/dl, dan juga terapi asam
mefenamet 1× 1/oral dengan dosis 500 mg.

CASE

Ny. K. O comes Oesapa Puskesmas with pain complaints in the lower abdomen with a duration
of 5 minutes, in addition, the goal is also to be given education about the technique of
breastfeeding and birth control. In addition, education about immunisation is also provided. The
results of the test were obtained TD: 110/80, N: 82 ×/min, S: 36, 5Oc with a pain scale of 3, as
well as the results of the HB Lab: 93 g/DL, and also therapy mefenamet acid 1 × 1/oral at a dose
of 500 mg.
 POST PARTUM MOTHER ASSESSMENT FORMAT

Student name : Victoria Pandie

Entry Date : May 27, 2019
Room / Class : Flamboyant / III
Assessment date: May 27, 2019
NIM : PO.530320116279
Entrance hours: 07: 00
Room no :2
Hours : 9:00

I. GENERAL IDENTITY
Patient's name: Mrs. K.O
Age : 27 years
Ethnic group : Timor / Indonesia
Religion : Protestant Christianity
Education : elementary school
Occupation : Housewife
Address : Oesapa
Marital status : married
Obstetric history: G4, P3, A1, AH 2org
Post partum day to: 2
Husband's name: Mr. M.S.
Age : 37 years old
Ethnic group : Timor / Indonesia
Religion : Protestant Christianity
Education : elementary school
II. MEDICAL HISTORY
a. Pregnancy check-up place : Oesapa Health Center
b. Frequency : 6 times
c. Immunization : TT

d. Complaints during pregnancy: The patient says cramps

e. Health education that has been obtained: Never received
health education such as breast care, nursing mothers
nutrition, baby nutrition and others

III. LABOR HISTORY

a. Place of delivery : Hospital
b. Helper : Midwife
c. The course of labor
d.First stage : complete opening

Stage II : the baby is born crying right away

Third stage: birth of the placenta

Stage IV : no tears, generally good,

N: 78x / minute,
S: 36.5

IV. PHYSICAL EXAMINATION OF MOTHER

a. TTV: TD: 90 / 60mmHg,
b. N: 82xmin,
c. S: 36.5 °
d. C, RR: 20x / minute
b. General inspection
1. General circumstances: Good
2. Consciousness: compositional
3. Deformed body: there are no abnormalities in the body
c. Head / face
1. Scalp: no dandruff, lesions / wounds, no pain
2. Eyes: conjunctival anemic
3. Ears: both ears symmetry. At the time of examination there were no injuries
4. Nose: no polyps
5. Mouth / Tooth mucosa: Moist, clean-looking teeth
e. Neck
1. Tyroid gland: no enlargement of the thyroid gland
2. Lymph glands: no enlarged lymph nodes

f. Chest
1. Breast shape: both breasts appear symmetrical,
2. Milk nipples: During inspection the milk nipples are prominent
3. Pigmentation: when inspection occurs pigmentation / linea alba
4. Colostrum: at the time of palpation the color of colostrum is yellow
5. Breast hygiene: breasts look clean

g. Stomach
1. High fundus uteri: at the time of TFU examination
the patient is 3 fingers under the umbilicus
2. Chewiness: when palpation feels hard
3. Abdominal Rectus Diastasis Length: 7cm Wide
g. Vulva
1. Lochea: 2cm
2. Amount: A lot
3. Type: Rubra (Brownish red)
4. Odor: unpleasant
 5. Cleaning: yes
6.
h. Perineum: intact. There is no tear / rupture
i. Hemorrhoids: none
j. Extremities: no phlebitis, varicose veins, and edema

V. BASIC NEEDS
a. Nutrition
1. Food pattern: Good
2. Frequency: 3 times a day
3. Type of Food: Rice, vegetables, tempeh, and meat
4. How is mother's knowledge about
5. Breast care: compress with warm water
6. How to breastfeed: mothers do not understand how to breastfeed properly, the baby
looks confused putting, the baby's mouth does not cover the entire areola
Umbilical cord care: mother knows how to care for the
umbilical cord
7. How to bathe the baby: mother knows how to bathe the baby
8. Baby nutrition: the mother knows the nutrition for the baby which is breast milk
9. Nutrition for nursing mothers: fish vegetables, tempeh, tofu, meat
10. Family planning: mothers do not understand family planning, because they do not really
know about the methods of family planning
11. Immunization: know about the benefits of immunization that is to Prevent disease

j. Health education needed

1. payudara Breast care: no
2. How to breastfeed: yes
3. Umbilical cord care: no
4. How to bathe a baby: no
5. Baby nutrition: no
6. Nutrition of nursing mothers: no
 7. Family planning: yes
8. Immunization: no

k. Spiritual data
1. Religion: the patient is a Protestant Christian
2. keagamaan Religious activities: patients can usually go to church and worship
Household
3. Is the patient confident in the religion being professed: yes. Patient sure
I. Supporting Data
- Blood Laboratory: Hb 9.3 g / dl
- Ultrasound: no
VI. THERAPY I: Mefenamet Acid 1x1 / orally with
500mg dose

B. DATA ANALYSIS

Data etiology Masalah keperawatan

1. Subjective data: Patients Biological injury agent Pain
complain of pain in the lower
abdomen. pain felt when
moving its like prickling and
disappearing arise, in the
lower abdomen scale 3, long
pain 5 minutes
2.Objective data: The patient
appears to hold the abdomen,
and the face grimaces.
Biological injury agents. Pain
C. NURSING INTERVENTIONS
Diagnosa
Acute pain b / d biological
injury agents
NOK NIK
Goal: Patients will maintain Control Criteria results:
comfort during - able to control pain
NOC: Pain (know the cause of pain)
- Able to use non-
pharmacological techniques to
reduce pain
- Report that pain is reduced
by using NIC: Pain
Management
1. Perform a comprehensive
assessment of pain, including
location, quality and factors
precipitation
2. Observe non-verbal
reactions to discomfort
3. Teach non-pharmacological
techniques
4. Increase rest
5. Environmental control
NURSING IMPLEMENTATION AND EVALUATION

Hari /tgl /jam Diagnosa Implementasi Evaluasi

keperawatan
Monday, 27 Acute pain b / d relaxation techniques S: The patient says
May biological injury agent (deep breathing) pain has subsided
2019/10: 20 - Invite patients O: pain scale 3 to pain
story telling scale 1, patient's face
(distraction) looks relaxed, TTV:
- Serving mefenamet TD: 110/80, N:
acid 82x / minute, RR:
1x1 / oral 20x / minute, S: 36.5 °
- Monitor TTV: TD: C
110/80, N: 82x / A: The problem of
minute, RR: pain resolved
20x / minute, S: 36.5 ° P: Intervention
C stopped