BASIC CONCEPTS OF NURSING CARE

RISK OF INJURY

Disusun Oleh

INDANA ZULFA

2014901064

POLITEKNIK KESEHATAN KEMENKES TANJUNGKARANG

JURUSAN KEPERAWATAN
PRODI PROFESI NERS
TAHUN 2020
 BASIC CONCEPTS OF NURSING CARE
RISK OF INJURY

A. General Assesment
1. client identity
Assessment date : 15 mei 2019
Time :11.50 WIB
Name : Ny. Y
Age : 40 years
Addres : Batu Raja
Gender : female
Status : Married
religion : moslem
Profession : housewife

2. Current Medical History:

The client comes to the hospital with a referral from the puskesmas with HbSAg (+),
G4P3A0 at 11.20 WIB. On arrival at the hospital the client complained of severe pain,
when a leopold 1 examination was carried out, uterine fundal height: 33cm, leopold 2,
the fetus back was located on the right with Djj 137x / minute, the fetus had entered the
upper pelvis, Her every 10 minutes duration < 20 seconds 4 times, when checked in, the
client has opened 5, with the percentage of the head.
3. Main Complaints During the Assessment

The client said the pain was severe and like wanting to defecate, the pain scale was 9
(1-10). And his, every 10 minutes <20 seconds in duration, 4 times when the client
review is complete, the gestational age is 37 weeks, Djj 139x / minute.
 B. Nursing Assesment
1. General Appearance

The awareness level of the Compos Mentis E4M6V5 client, the client akral feeling cold,
the client looks icteric, the client skin turgor is elastic, the client has a history of HbSAg
disease, the client does not experience edema, the client looks anxious and restless.
Vital sign
Blood pressure : 120/90 mmHg
Pulse : 80x / minute
Inhalation : 28x / minute
Temperature : 36.6 ° C

2. . Respiration Assessment

During labor, the client looks congested, the client does not cough, does not use
breathing muscles, the client does not experience tachypnea, bradipnea, tachycardia, the
client's consciousness is compos mentis and the client looks restless because she
experiences pain.

3. Circulation Assessment

The client does not experience bradycardia, tachycardia, the client bleeds approximately
500cc from delivery until the placenta comes out, the client does not experience jugular
vein distension, the client does not experience oliguria, the client looks tired when
straining, CRT <3 seconds, the client experiences paresthesia during labor.

4. Nutritional and Fluid Assessment

the client experiences abdominal pain due to contractions, the client does not
experience swallowing problems, does not experience thrush, does not experience
diarrhea, does not complain of thirst, and the client does not experience a decrease in
body weigt.

5. Elimination Assessment

The client's bladder is not full, the client says her urine comes out a little bit, the
client does not experience dysuria, the client says it has been 3 days before
defecating (constipation).

6. Activity and Rest Assessment

The client said that the pain when moving, the client's muscle strength did not
decrease, the client did not experience joint stiffness, the client's physical condition
was not weak, the client did not look lethargic and tired.
7. Neurosensory Assessment

The client does not complain that there is a neurosensory disorder. The client does
not have a headache, has no spinal cord injury, does not complain of difficulty
swallowing, does not cough before swallowing, does not cough after eating and
drinking, does not experience hematemesis, and does not drool.

8. Assessment of Pregnant Women and Childbirth

Punch. 11.50 WIB the 1st time

Active Phase: the client experiences 4 contractions every 10 minutes <20 seconds in
duration and 5 cm of opening.
Transition Phase: the client experiences 4 contractions every 10 minutes <20 seconds
in duration with complete opening.

Stage II
The client has a complete opening with contractions increasing every 10 minutes for
50 seconds as much as 4 times, the water breaks with a clear color, you can feel the
pressure in the perenium area, the client experiences tears during labor.

Stage III
At 12.30 the baby was born spontaneously with the male gender, weight
2700 grams, body length 46 cm, complete placenta is round
with a diameter of 15cm, 2.5 cm thick with a weight of 500 grams, the blood that
comes out of the I-III stage is ± 500cc.

Stage IV
Time: 15.00 WIB
Blood pressure: 120/80 mmHg, pulse: 80 x / minute, respiration: 24 x / minute,
temperature: 36.6 ° C, empty bladder, bleeding ± 200 cc, client awareness
composmentis, TFU: 2 fingers below the center

9. . Pain and Comfort Assessment

The client complains of pain on a scale of 9 (1-10), the client says like she wants to
defecate, the client says the pain is getting more and more frequent, the pain is
prickling, the client looks restless, the client looks grimace, the client does not
experience diaphoresis, the client does not complain of itching .

10. Psychological Assessment

The client does not experience psychological problems. The client was not tense, the
client did not feel confused, the client did not cry, was not angry, and the client did
not seem panicked.

11. Personal Hygiene Assessment

The client is unable to go to the toilet by herself so she needs help to go to the toilet,
the client does not refuse to do self-care such as,
wiping the bod
 D. Nursing Diagnose
1. The risk of injury to the fetus is characterized by pain in the abdomen, the fetus is in a mal
position (posterior position), the membranes are broken.

cues Nursing Goals/ interventio rasionale Evaluation

diagnosa objective n
Subjective The risk After 3x24 Fetal heart 1. For After nursing
Data: of injury hours of rate knowing Intervention it is
1. the client to the nursing care, monitoring. client's expected that the fetus
says pain in fetus is the fetus is 1. Identify condition is normal with
the stomach associated expected to be the use of can cause predetermined outcome
2. The client with pain normal, with drugs, diet injury criteria
says pain in in the the following and
the birth abdomen, criteria: smoking. 2. To
canal the fetus Fetal status: know the
3. client age is in a mal Intrapartum 2. Monitor general
40 years position 1. Normal mother's state of the
Objective (posterior amniotic color vital signs client
data: position), 2.Basic fetal and position
1.the fetus the water heart rate (120- her. 3. To
has a mal breaks. 160) reduce
position normal 3. risk of
(posterior The position of Encourage injury,
position) the fetus is not lying down secure
2. Your disturbed in bed. environme
water breaks nt and
4. Check create
baby's heart convenien
rate for 1 ce for
minute. clients

4. to
ensure the
baby's
heart rate
12 Implementatio 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12
Octobe n a. a. a. a. a. a. p. p. p. p. p. p. p. p. p. p. p. p.
r 2020 m m m m m m m m m m m m m m m m m m
1. Identify the √
use of drugs,
diet and
smoking
2. Monitor √ √ √ √
mother's vital
signs and
position her.

3. Encourage √
lying down in
bed.

4. Check baby's √ √
heart rate for 1
minute.
Name : Ny. Y
No. RM : 223354
Age : 40 y.o
Date / Time Doctor / Nurse Health Team Signature
08 October 2020 Nurse S: INDANA
- The client said pain in
the stomach
- Client says the
contractions are
increasing
O:
- The client looks
exhausted
- Djh: 140x / minute
- TD: 120/80 mmHg
- Pulse: 80x / minute
- Breathing: 22x /
minute
- Temperature: 36.5 °
C

A: the problem of risk

of injury to the
fetus has not been
resolved.

P: continue the
intervention.
Identify the use of
drugs, diet and
smoking