INTRODUCTION REPORT

Hyperemesis gravidarum
To fulfill the task of maternity nursing clinic practice 1

Name : Nadia Tara Dila

NPM : 1914201310078
Semester : III
Hospital : Islam Banjarmasin
Group : 1 Bilingual
Clinical Advisor : Nurhikmah, S.Kep.,Ns
Academic counselors : Esme Anggraini, Ns.,M.Kep

BILINGUAL NURSING STUDY PROGRAM

FACULTY OF NURSING AND HEALTH SCIENCE
MUHAMMADIYAH BANJARMASIN UNIVERSITY 2020-2021
STUDENT IDENTITY
NAME : Nadia Tara Dila
NPM : 1914201310077
HOME BASE : Rumah Sakit Islam Banjarmasin
CI : Nurhikmah, S.Kep.,Ns
CT : Esme Anggraini, Ns.,M.Kep
HP/WA : 081254434003
ALAMAT : Jl. Belitung darat. Gg bina warga, No. 397
PRODI : S1 KEPERAWATAN BILINGUAL

1
 BAB

II REVIEW

THEORY

A. Pengertian

Hyperemesis gravidarum is a condition in which sufferers of excessive nausea and vomiting,

more than 10 times in 24 hours or at any time, so that it interferes with their health and daily

work (Arief. B., 2009).

Pregnant women vomit everything they eat and drink so that their body weight drops, skin

turgor is reduced, dieresis is reduced and acetone is present, this condition is called hyperemesis 2
gravidarum (Sastrowinata, 2004).

Hyperemesis gravidarum is excessive or uncontrollable vomiting during pregnancy, which

causes dehydration, electrolyte imbalance, or nutritional deficiencies, and weight loss

(Lowdermilk, 2004).

So the conclusion that the authors can take, hyperemesis gravidarum is excessive nausea and

vomiting that can interfere with daily uncontrolled activities during pregnancy causing

dehydration, electrolyte imbalance or nutritional deficiency and weight loss.

3
B. Concept of Pregnancy
1. Pregnancy

Pregnancy is the period from conception until the birth of the fetus.

Normal gestation duration is 280 days or 40 days or 9 months and 7 days,

calculated from the first day of the last menstruation (Saifuddin, 2002).

A mature (term) pregnancy lasts approximately 40 weeks (280 days) and not

more than 43 weeks (300 days). Pregnancy lasts between

28 and 36 weeks are called premature pregnancies, while more than 43 weeks

are called post-mature pregnancies (Manuaba, 2005).

2. Signs of Pregnancy

a. The signs of pregnancy are uncertain

1) Amenorrhoea (unable to menstruate). This symptom is very important

because generally pregnant women can no longer menstruate. It is

important to know the date of the first day of the last menstruation, so

that you can determine how old the pregnancy is and if labor is

expected to occur.

2) Nausea (nausea) and emesis (vomiting). Nausea occurs generally in

the first months of pregnancy, accompanied occasionally by emesis.

Often occurs in the morning, but not always. This condition is

commonly called morningsickness

3) Cravings (want special / certain foods). Cravings often occur in the

first months but disappear as the pregnancy gets older.

4) . Fainting Often found when in crowded places. It is advisable not to go to

crowded places in the first months of pregnancy. Disappeared after 16 weeks
of pregnancy.

5) Anorexia (No appetite). In the first months there is anorexia, but after

that the appetite arises again.

6) Frequent urination occurs because the bladder is pressed by the

enlarged uterus. These symptoms will disappear in the second

trimester of pregnancy. At the end of pregnancy, these symptoms

return, because the bladder is pressed by the vaginal head.

7) Obstipation occurs due to decreased muscle tone caused by the

influence of steroids.

8) Skin pigmentation occurs at 12 weeks of gestation and above. On the

cheeks, nose and forehead, there are sometimes excessive deposits of

pigment, known as chloasma gravidarum. The areola mammae also

becomes darker because of the excess deposits of pigment. The neck

area becomes darker. Likewise, the linea alba in the midline of the

abdomen becomes darker (linea griea). This pigmentation occurs due

to the influence of the placental cortico-steroid hormone which

stimulates the melanophore and skin.

9) Epulis is a hypertrophy of the gingivae papillae, often occurring in the

first trimester.
 10) Varicose veins. Often found in the last quarter of the last quarter.

Obtained in the area of the external genitalia, popliteal fossa, legs

and calves. In multigravida varicose veins are occasionally found in

previous pregnancies, recurring in the first trimester. Sometimes the

appearance of varicose veins is the first symptom of a young

pregnancy (Wiknjosastro, 2005).Tanda pastikehamilan

11) On palpation, the fetus is felt and the ballotement and fetal movements
are felt.

12) On auscultation, a fetal heart sound (BJJ) was heard. With a BJJ

laennec stethoscope audible at 18-20 weeks of gestation. With the BJJ

Doppler device heard at 12 weeks of gestation.Dengan ultrasonogravi

(USG) atau scannig dapat dilihat gambaran janin.

13) The X-ray shows the fetal skeleton. Not done anymore now because

of the impact of radiation on the fetus (Arif, 2000).

3. Physiological Adaptation to Pregnant Women

a) Uterus

b) The uterus will enlarge in the first months under the influence of increased
levels of estrogen and progesterone. This enlargement is basically caused
by hypertrophy of the smooth muscle of the uterus; In addition, the
collagen fibers become hygroscopic due to the increase in estrogen levels
so that the uterus can follow the growth of the fetus. If there is an ectopic
pregnancy, the uteru will also get bigger, because of the influence of these
hormones. Likewise the endometrium becomes decidua.

c) The normal uterine weight is approximately 30 grams; at the end of

pregnancy (40 weeks) the weight of the uterus becomes 1000 g with a
length of 20 cm and a wall of 2.5 cm. In the first months of pregnancy,
the uterus resembles a slightly flattened avocado. At 16 weeks of
gestation, the uterus is round. Then at the end of pregnancy it returns to
its original shape, oval like an egg. The relationship between the size of
 the uterus and the length of the pregnancy is very important to know,
among other things, to form a diagnosis, whether the woman is pregnant
with physiologic, multiple pregnancy or suffering from a disease such as
hydatid mole and so on.

d) In the first weeks of the uterine ismus is hypertrophied like the corpus
uteri. The hypertrophy of the isthuses in the first trimester makes the
isthuses longer and softer. This is known in obstetrics as a sign of vigor.

e) ServiksUteri

The uterine cervix in pregnancy also changes due to the hormone

estrogen. As a result of increased estrogen levels and

hypervascularization, the cervix becomes soft in consistency. The

uterine cervix contains more connective tissue consisting of collagen.

Because the cervix consists of connective tissue and contains only a

small amount of muscle tissue, the cervix does not have a function as a

sphincter, so that during labor, the cervix will just open following the

upward pulling of the uterine body and the lower pressure of the fetus.

After delivery, the cervix will appear folded and does not close like a

sphincter. Changes in the cervix need to be known as early as possible in

pregnancy, but the examiner should be careful and not justified in doing

it roughly, so that it can upset the pregnancy.

The glands in the cervix will function more and will release more

secretions. Sometimes women who are pregnant complain of more

vaginal discharge. In this state to some extent it is still a physiological

state.

f) Vagina danvulva

Hypervascularization causes the vagina and vulva to appear redder and

 slightly bluish (livide). The color of the portion looks livide. The blood

vessels of the internal genetalia will enlarge. This is understandable

because of the oxygenation and nutrition of the genetal organs

increase. If there is an accident during pregnancy / childbirth, the

bleeding will be a lot, which can lead to death.

g) Ovarium

At the beginning of pregnancy there is still a corpus luteum

graviditatis until the placenta has formed at about 16 weeks of gestation.

The corpus luteum gravidity is approximately 3 cm in diameter. Then, it

shrinks after the placenta has formed. As already stated, this corpus

luteum secretes the hormones estrogen and progesterone. Gradually this

function is taken over by the placenta. In the last decade, the hormone

relaxin, an immunoreactive inhibin in the maternal circulation, was

discovered at the onset of ovulation. It is thought that the corpus luteum

is the synthesis site of relaxin in early pregnancy. Maternal circulating

relaxin levels can be determined and increase in the first trimester.

Relaxin has a calming effect until the fetus grows well to its temperature.

h) Mamma

Mamma will be enlarged and tense due to the hormones

somatomammotropin, estrogen, and progesterone, but has not released

milk.

Estrogen gives rise to duct system hypertrophy, whereas progesterone

adds acini cells to the mammary.

 LSomatomammotropin affects the growth of acini cells as well and

causes changes in the cells, resulting in the production of casein,

lactalbumin, and lactoglobulin. Thus the mamma is prepared for

lactation. In addition, under the influence of progesterone and

somatomammotropin, fat is formed around the alveolar groups, so that

the mammary becomes bigger. The mammary papillae will be enlarged,

straighter, and appear black, like the entire areola of the mamma due to

hyperpigmentation. Montgomery's glands are more prominent on the

surface of the areola mamma. At 12 weeks of pregnancy and above,

from the nipple a slightly clear white discharge is called colostrum. This

colostrum comes from the acini glands which begin to secrete

i) SirkulasiDarah

Maternal blood circulation in pregnancy is influenced by the

circulation to the placenta, an enlarged uterus with enlarged blood

vessels, breasts and other devices that are overworked in pregnancy.

Maternal blood volume during pregnancy increases physiologically in the

presence of liquefaction of blood called hydremia. Blood volume will

increase by ± 25% at the peak of 32 weeks of gestation. Although there

is an increase in the volume of erythrocytes as a whole, the increase in

plasma volume is much greater and the hemoglobin concentration in the

blood is lower. Although this hemoglobin level decreases to

± 120 g / L. At week 32, pregnant women have a greater total

hemoglobin than these women when they are not pregnant.

Simultaneously, the white blood cell count increased (± 10,500 / ml), as

 did the platelet count.

To overcome the increase in blood volume, cardiac output will

increase by ± 30% at week 30. Most of the increase in cardiac output

was due to an increase in stroke volume, however, the heart rate

increased by ± 15%. After a pregnancy of more than 30 weeks, there is a

tendency for an increase in blood pressure

j) Respiration system

Breathing is still diaphragmatic during pregnancy, but because

diaphragmatic movement is limited after week 30, pregnant women

breathe more deeply, increasing tidal volume and ventilation rate,

allowing increased gas mixing and increased oxygen consumption by

20%. It is thought that this effect is due to increased progesterone

secretion. This condition can cause exhalation and lower arterial PO2.

In late pregnancy, the lower ribs widen out slightly and may not return to

their pre-pregnancy state, causing concern for women who pay attention

to their body appearance.

k) Traktus Digetivus

In the mouth, the gums become soft, possibly due to retention of

intracellular fluid caused by progesterone. The esophageal sphincter

relaxes, so it can occur regorgitation of the stomach which causes

burning in the chest (heathburn). The secretion of the stomach is reduced

and the food lasts longer in the stomach. The intestinal muscles relax

with decreased motility. This allows for greater absorption of nutrients,

but can cause constipation, which is one of the main complaints of

 pregnant women..

l) Urinarius tract

In the first months of pregnancy the bladder is compressed by the

enlarged uterus, resulting in frequent urination. This condition resolves

with the aging of the pregnancy when the uterus gravidus leaves the

pelvic cavity. At the end of pregnancy, the head of the fetus begins to

fall into the PAP, complaints of frequent urination and recurs because the

bladder starts to press again. Besides that, there is also polyurine.

Polyuria is caused by an increase in blood circulation in the kidneys in

pregnancy so that the glomerular filtration rate also increases by 69%.

Tubular reabsorption does not change, so that excretion products such as

urea, uric acid, glucose, amino acids, folic acid are more excreted.

m) System of Law

Changes in pigment deposits and hyperpigmentation due to the

influence of melanophore stimulating hormone (MSH), the influence of

the anterior pituitary lobe, and the influence of the suprarenal gland. This

hyperpigmentation occurs in the striae gravidarum lividae or alba, areola

mamae, papilla mamae, linea nigra, and cheeks (chloasma gravidarum).

After delivery this hyperpigmentation will disappear. Changes in skin

conditions that have turned upside down from its original state, which

was usually (when not pregnant) dry skin, now it will become oily, and

vice versa. This happens because of hormonal changes in the body of

pregnant women. Hair becomes drier or oilier due to changes

n) Metabolism in pregnancy
 BMR increases up to 15-20% which is generally found in the

third trimester. The calories needed for this are obtained mainly from

burning carbohydrates, especially after 20 weeks of pregnancy and over.

However, if needed, use maternal fat to get additional calories in daily

work. Under normal circumstances pregnant women are quite

economical in terms of energy use.

The fetus needs 30-40 grams of calcium for the formation of

bones and this occurs especially in the last trimester. Food each day is

estimated to contain 1.5-2.5 grams of calcium.

It is estimated that 0.2-0.7 grams of calcium is retained in the

body for purposes during pregnancy. This is sufficient for fetal growth

without compromising maternal calcium. The level of calcium in the

serum is indeed lower, perhaps due to hydremia, but the calcium level is

still high enough to overcome the possibility of tetany seizures.

Immediately after late menstruation, the level of the enzyme

diamino-oxidase (histamine) increases from 3-6 units in the nonpregnant

period to 200 units at 16 weeks of pregnancy. These levels peak up to

400-500 units at 16 weeks of gestation and beyond until the end of

pregnancy. Chinosinase is an enzyme that can make oxytocin inactive.

Pinositase is found abundantly in the mother's blood at 14-38 weeks of

gestation.

Pregnant women will gain weight between 6.5-16.5 kg, an

 average of 12.5 kg. This weight gain occurs mainly in the last 20 weeks

of pregnancy. Weight gain in pregnancy is caused by conception, fetal

placenta and liquor (Wiknjosastro, 2005).

4. Psychological Adaptations in Pregnant Women

First trimester; Doubtful about her pregnancy, ambivalent (conflicted

feelings) and more self-focused. In this trimester,

the feeling of discomfort due to feelings of nausea, vomiting, and fatigue

often decreases sexual desire..

a) Second trimester

1) With the movement of the baby, the mother becomes convinced of

the baby's existence, and the mother feels confident that she will

soon have a baby.

2) The mother focuses more on her baby, she usually feels better than

in the first trimester and has not been disturbed by her activities.

3) Changes in body size for some people cause a change in body

image or a negative self-image.

b) Third trimester

1) Mother has started preparing for birth. Mother asks about signs of

labor to friends or relatives who have gone through the labor process .

2) Some women experience labor fears and feel uncomfortable in the

days leading up to labor.

 3) The mother prepares clothes, a place for the baby, and plans its care

(Hidayati, 2009).

Reproductive System Anatomy and Physiology

The anatomy of the uterine organs can be divided into 2, namely genetalia

externa and genetalia internal.

(Sobotta, 2006)

5. External Genitalia

a. Monsveneris

The prominent part includes the symphysis which is made up of fatty

tissue, this area is covered with hair at puberty.

b. Vulva

Is where the urogenital system empties. On the outside of the vulva is

circled by the labio majora (large lips) which go back, unite and form the

posterior and perineal commissures. Under the skin are fatty tissue like

those in monsveneris.
c. Labiomayora

The labio majora (big lips) are the two large folds that line the vulva,

consisting of skin, connective tissue, fat and sebum glands. During

puberty hair grows on the mons veneris and on the lateral side.

d. Labiominora

Labio minora (bibir kecil) adalah dua lipatan kecil diantara labio mayora,

dengan banyak kelenjar sebasea. Celah diantara labio minora adalah

vestibulum.

e. Vestibulum

The vestibule is a cavity between the small lips (labio minora), then the

back is bounded by the clitoris and perineum, in the vestibule there are

the estuaries of the intercourse hole (introetus vaginal urethra),

Bartholimi glands and left and right scene glands..

f. Himen (selaputdara)

The thin layer that covers most of the intercourse and the hole in the

middle is hollow so that menstrual discharge can flow out, the location of

the vaginal opening is in this part, the shape is different, some are like a

crescent moon, the consistency is stiff and soft, the hole is the tip of the

finger, there are one finger can pass through.

g. Perineum

Formed from the corpus perineum, the meeting point of the pelvic floor

muscles covered by perineal skin.

 (Sobotta, 2006)

6. Genetalia Interna

a. Vagina

The tube, which is covered with a membrane of the striped epithelium

type, is specially packed with blood vessels and nerve fibers. Its length

from vestibule to uterus is 7½ cm. Is a link between vaginal introitus and

uterus. The front wall of the intercourse (vagina) is 9 cm, shorter than

the back wall. At the top of the vagina, the fold is called rrugae.

b. Uterus

A thick, muscular, pear-shaped organ located within the pelvis between

the rectum at the back and the bladder at the front, its muscles are called

the myometrium. The uterus floats in the pelvis with connective tissue

and

ligament. The uterus is 7½ cm long, 5 cm wide, 2 cm thick.

Weight 50 gr, and weight 30-60gr.

The uterus consists of:

1) Fundus uteri (Dasarrahim)

The part of the uterus that lies between the bases of the fallopian

tubes. On antenatal care, uterine fundus touch can estimate

gestational age.

2) Korpusuteri
 The largest part of the uterus in pregnancy, this part serves as a place

for the fetus to develop. The cavity in the uterine body is called the

uterine cavity or ronggarahim.

3) Servixuteri

The end of the cervix that leads to the top of the vagina is called the

portiono, the connection between the uterine cavity and the cervical

canal is called the ostium uteri internum.

Uterine lining, covering :

1) Endometrium

2) Myometrium

3) Parametrium

c. Ovarium

It is a walnut-shaped gland, located left and right of the uterus under the

uterine tube and bound behind by the broad ligament..

d. TubaFallopi

The fallopian tubes are lined with ciliated epithelium arranged in multiple

folds, which slows down the passage of the ovum into the uterus. Some

of the fallopian cells secrete serous fluid which provides nutrition to the

ovum.

The fallopian tube is also called the fallopian tube, there are 2 left and

right fallopian tubes. Length about 12 cm but not running straight. Then

there are fimbria at the edges, to hug the ovum during ovulation to enter

the tube (Tambayong, 2002).

C. Etiology

The cause of hyperemesis gravidarum is not certain. There is no evidence

that the disease is caused by toxic factors, nor is there any biochemical

abnormalities. Anatomic changes in the brain, heart, liver, and nervous system,

caused by a deficiency of vitamins and other substances due to initiation. Some of

the predisposing factors and other factors that have been found by several authors

are as follows:

1. Faktor predisposisi : primigravida, overdistensi rahim : hidramnion, kehamilan

ganda, estrogen dan HCG tinggi, molahidatidosa.

2. Organic factors: entry of chorial villi in the maternal circulation, metabolic

changes due to pregnancy, decreased resistance on the part of the mother and

allergies

3. Psychological factors: fractured household, unwanted pregnancy, fear of

pregnancy and childbirth, fear of responsibility as a mother and loss of work

(Wiknjosastro, 2005).

D. Patofisiologi
Hyperemesis gravidarum, which is a complication of nausea and vomiting in

young pregnant women, occurs continuously and can cause dehydration and

electrolyte imbalance with hypochloremic alkalosis.

 Hyperemesis gravidarum can result in carbohydrate and fat reserves being

used up for energy purposes. Due to incomplete oxidation of fats there is ketosis

with the accumulation of acetone-acetic acid, hydroxy butyric acid and acetone in

the blood. Lack of volume of fluids drunk and loss due to vomiting leads to

dehydration so that extracellular fluid and plasma are reduced. Sodium and

chloride drop in urine. In addition, it can also cause hemoconcentration so that

blood flow is reduced. Lack of potassium as a result of vomiting and increased

excretion through the kidneys increases the frequency of vomiting more, can

damage the liver and create a cycle that is difficult to break.

In addition to dehydration and disruption of electrolyte balance can occur

tearing of the mucous membrane of the esophagus and stomach (Mallory Weiss

Syndrome) with the result of gastrointestinal bleeding. In general, these tears are

mild and bleeding can stop on its own, rarely until transfusion or surgery is needed

(Wiknjosastro, 2005).

E. Clinical Manifestations

There is no clear boundary between physiological nausea in pregnancy and

hyperemesis gravidarum; but if the general condition of the patient is affected, this

should be considered as hyperemesis gravidarum. Hyperemesis gravidarum

according to the severity of the symptoms can be divided into 3 levels:

1. Level I: Vomiting continuously which affects the general condition of the

patient, the mother feels weak, has no appetite, loses weight and feels pain in

the epigastrium. pulse increases about 100 beats / minute and systolic blood

pressure decreases, skin turgor decreases, tongue dries up and eyes are sunken.
 2. Level II: the patient looks weaker and apathetic, the skin turgor decreases, the

tongue dries up and looks dirty, the pulse is small and fast, the temperature

sometimes rises and the eyes are slightly icteric. Body weight decreases and

the eyes become sunken, decreased tension, hemoconcentration of oliguria and

constipation. Acetone can be smelled in the air, because it has a distinctive

aroma and can also be found in urine.

3. Level III: The general condition is more severe, vomiting stops, consciousness

decreases until it reaches somnollen or coma, there is werniche encephalopathy

which is characterized by: nystagmus, diplopia, mental disorders,

cardiovascular characterized by: small pulse, decreased blood pressure, and

increased temperature, gastrointestinal characterized by: the jaundice is getting

heavier, there is a higher accumulation of acetone with an increasingly sharp

odor. This situation is the result of a severe deficiency of food substances,

including vitamin B complex. The onset of jaundice indicates a heartache

(Wiknjosastro, 2005).

F. Diagnosis

The diagnosis of hyperemesis gravidarum is usually not difficult. Must

determine the presence of early pregnancy and vomiting continuously, thus

affecting the general condition. However, it should be considered early pregnancy

with pyelonephritis, hepatitis, ventricular ulcers and cerebral tumors which can also

cause vomiting symptoms.

 Continuous hyperemesis gravidarum can cause food shortages that can affect

fetal development, so treatment needs to be done immediately (Wiknjosastro,

2005).

G. Prevention

1. The principle of prevention is to treat emesis so that hyperemesis gravidarum

does not occur by:

2. Provide application of pregnancy and childbirth as a physiological process.

3. Provides confidence that nausea and sometimes vomiting are physiological

symptoms of early pregnancy and will disappear after 4 months of gestation.

4. He recommends changing daily meals with small, but frequent, meals

5. Suggests that when you wake up in the morning don't get out of bed

immediately, first eat dry bread or biscuits with warm tea

6. Foods that are greasy and smell of grease should be avoided

7. Food should be served hot or very cold

8. Avoiding cardohydrate deficiency is an important factor, it is recommended that

foods that contain lots of sugar (Wiknjosastro, 2005)..

H. Management

If the above complaints and symptoms do not reduce, it is necessary:

1. Drugs; Sedativa: Phenobarbital, Vitamins: Vitamin B1 and B6 or B - complex,

 Anti-histamine: dramamine, avomin, Anti-emetic (in more severe situations):

Dislikomin hydrochloride or chlorpromasine. Hyperemesis gravidarum that is

more severe needs to be managed in a hospital.

2. Isolation; The patient is alone in a room that is quiet, but bright and has good air

circulation, record the fluids that go in and out, only doctors and nurses can

enter the patient's room until vomiting stops when the patient wants to eat. Not

given food or drink and for 24 hours. Sometimes with isolation alone the

symptoms will improve or disappear without treatment.

3. Psychological therapy; need to convince sufferers that the disease can be cured,

eliminate fear due to pregnancy, reduce work and eliminate problems and

conflicts.

4. parenteral fluid; adequate fluid electrolytes, carbohydrates and protein with 5%

glucose in physiological fluids (2 - 3 liters / day), can be added with potassium

and vitamins (vitamin B complex, vitamin C), if protein deficiency can be

given amino acids intravenously, if in 24 hours the patient does not vomit and

the general condition improves, can be given drinks and gradually non-liquid

food. With the above treatment, in general, the symptoms will decrease and

the situation will get better.

5. Terminate pregnancy; If the condition worsens, medical and psychiatric

examinations are carried out, manifestations of organic complications are

delirium, tachycardia, jaundice, anuria and bleeding in such circumstances it is

necessary to consider terminating the pregnancy.:

a. Psychiatric disorders characterized by: delirium, apathy, somnolence to

coma, psychiatric disorders.

 b. Visual disturbances characterized by: retinal bleeding, deterioration of

vision.

c. Physiological disorders characterized by: the liver in the form of jaundice,

the kidneys in the form of anuria, the heart and blood vessels have

increased pulse, decreased blood pressure. (Wiknjosastro, 2005).

I. Complications

Wernicke's encephalopathy with symptoms of nystagmus, diplopia and

mental changes, and heart trouble with symptoms of jaundice. (Arif, 2000)..
 1. Pathways
Kehamilan

Perubahanfisiologis Perubahan Psikologis

Hormon HCG estrogen Krisis Kuranginformasi

Ancaman kehilangan janin Kurang pengetahuan

Motilitas lambung dan usus
Cemas

Kembung dan produksi gas Nafsu makan menurun

Kurang volume cairan dan BB turun BBKurangnya

turun pemenuhan kebutuhan nutrisi
Mual dan muntah elektrolit
Lemah
Cairan elektrolit keluar Peningkatan suhu tubuh

Tugor kulit menurun/jelek

Intoleransi
Resiko kerusakan integritas
kulit

(Wiknjosastro, 1999:27)

27
2. Nursing Diagnosis and Intervention

a. Less than necessary nutritional changes are associated with persistent nausea

and vomiting.

Purpose : nutritional needs are met

outcome criteria :

1) The client will consume an oral diet that contains adequate nutrients.

2) The client does not experience nausea and vomitus.

3) The client will tolerate the programmed diits.

4) The client will experience a corresponding increase in body weight during

pregnancy.

Intervention :

1)
Record intake and output.
Rational: determine the hydration of fluids and spending through
vomiting..

2) Encourage eating small portions but often

Rational: can meet the nutritional intake the body needs.

3) Encourage eating a snack such as biscuits, bread and warm (hot) tea

before waking up during the day and before bed. 25

Rationale: snack food can reduce or avoid excessive stimulation of nausea

and vomiting
4) Catalytic TPN intake, if oral intake cannot be given within a certain

period.

Rational: to maintain a balance of nutrition.

26

DAFTAR PUSTAKA
Andreou,E. Alexopoulos, E.C. Lionis, C. Varvogli, L. Gnardellis, C. Chrousos, G.P,Darviri,

C. (2011) Perceived Stress Scale: Reliability and Validity Study in Greece. Int. J.

Environ. Res. Public Health.

Arginia Della Octaviadon. 2011. Hubungan Dukungan Suami terhadap Kehamilan dengan

Kejadian Hyperemesis Gravidarum. Surakarta

Aril Cikal Yasa Ar. 2012. Hubungan Antara Karakteristik Ibu Hamil Dengan Kejadian

Hiperemesis Gravidarum Di Rsud Ujungberung Pada Periode 2010-2011. Bandung.

http://elibrary.unisba.ac.id/files2/Skr.12.00.10854.pdf

Arikunto, S. 2010. Prosedur Penelitian Suatu pendekatan praktik. Jakarta: PT. Rineka Cipta.

Chadolirotul, M. 2012. Hubungan Paritas dan Umur Ibu dengan Anemia pada ibu hamil

trimester III. Semarang

Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J. Health Soc.

Behav. 1997 Denise. 2008. Mual dan Muntah Kehamilan. Jakarta : EGC.

Dewi S. 2012. Hubungan umur dan paritas ibu dengan berat bayi lahir di RB citra insane.

Semarang

Guyton A.C., Hall J.E. 2006. Buku Ajar. Fisiologi Kedokteran Edisi 11.Jakarta: EGC,

Hanifa. 2007. Ilmu Kebidanan. Jakarta : Yayasan Bina Pustaka.

Hanun Mukhlida, 2011. Konsep dalam Mengatasi Stress. Jakarta

Hawari, Dadang. (2008). Manajemen Stres Cemas dan Depresi. Jakarta : FK Universitas

Indonesia

Hidayat Alimult. 2007. Metode Penelitian Kebidanan Dan Tehnik Analisis Data. Surabaya:

College student

27

Nadia Tara Dila

NPM. 1914201310078
 To agree

Clinical Advisor Academic Advisor

Nurhikmah, S.Kep.,Ns Esme Anggeriyane, Ns.,M.Kep

NIP. 1096 NIDN. 1131129002

Student name : Nadia Tara Dila

NPM : 1914201310078
Room :-

28
NO Day/ Consul Material Feedback / Suggestions TTD Clinical
Date Advisor

29
 INTRODUCTION REPORT
CEPHALOPELVIC DISPRORTION (CPD)
To fulfill the task of maternity nursing clinic practice 1

Name : Nadia Tara Dila

NPM : 1914201310078
Semester : III
Hospital : Islam Banjarmasin
Group : 1 Bilingual
Clinical Advisor : Nurhikmah, S.Kep.,Ns
Academic counselors : Esme Anggraini, Ns.,M.Kep

BILINGUAL NURSING STUDY PROGRAM

FACULTY OF NURSING AND HEALTH SCIENCE
MUHAMMADIYAH BANJARMASIN UNIVERSITY 2020-2021

30
 STUDENT IDENTITY
NAME : Nadia Tara Dila
NPM : 1914201310077
HOME BASE : Rumah Sakit Islam Banjarmasin
CI : Nurhikmah, S.Kep.,Ns
CT : Esme Anggraini, Ns.,M.Kep
HP/WA : 081254434003
ALAMAT : Jl. Belitung darat. Gg bina warga, No. 397
PRODI : S1 KEPERAWATAN BILINGUAL

INTRODUCTION REPORT: CEPHALOPELVIC DISPRORTION (CPD)

INTRODUCTION REPORT

1. Definition
Cephalopelvic Disproportion (CPD) is a medical diagnosis used when a baby's head is deemed too large
to fit past the mother's pelvis.
Cephalopelvic disproportion is a condition that describes the incompatibility between the fetal head and
the mother's pelvis so that the fetus cannot pass through the vagina.
Cephalopelvic disproportion is caused by a narrow pelvis, a large fetus or a combination of both
Cephalopelvic disproportion is a condition that describes a mismatch between the fetal head and the
 pelvis of the mother so that the fetus cannot pass through the vagina.
Cephalopelvic Disproportion (CPD) is a medical diagnosis used when a baby's head is deemed too large
to fit past the mother's pelvis. Often times, this diagnosis is made after the woman has been toiling for
some time, but other times, it is entered into the woman's medical record before she is even a laborer.
A misdiagnosis of CPD accounts for the many unnecessary C-sections performed in North America
and around the world each year. This diagnosis does not have to impact a woman's future childbearing
decisions. Many steps can be taken by pregnant women to increase their chances of vaginal delivery.

2. Etiology
The causes that can cause pelvic abnormalities can be divided as follows:
a. Abnormalities due to growth disorders
1) The entire narrow pelvis: all small sizes
2) Hip picak: narrow back face size, usual cross size
3) Small narrow hips: all small sizes but especially the back face size
4) Pelvic funnel: ordinary upper pelvis, narrow pelvic doors.
5) Pelvis split: open symphyse

b. Abnormalities due to disease of the pelvis or joints

1) Pelvic rachitis: hip hip, narrow pelvis, whole narrow pelvis and others
2) Pelvic osteomalacci: narrow transverse pelvis
3) Inflammation of articulatio sacroilliaca: narrow pelvis oblique
c. Pelvic abnormalities caused by spinal abnormalities
1) Kyphose in the lumbar region causing the pelvis funnel
2) Sciliose area of the stilt bone causes a narrow pelvis tilt.
d. Pelvic abnormalities caused by lower limb abnormalities Coxitis, luxatio, atrophy. One member
causes a narrow pelvis to tilt. e. fracture of the pelvis which is the cause of pelvic abnormalities
(www.tabloid nakita.com/2009)

3. Patofisiologi

The pelvic bones consist of the coccyx, sacral, and coccyx bones. The os koksa can be divided into os ilium, os
ischium, and os pubis. These bones are connected to each other. In front there is a connection between the two
right and left pubic os, called the symphysis. Behind the sacro-iliac articulation, which connects the sacral os to
the os ilium. Below is the sacro-coccygeal articulation that connects the sacral os (tl pelvis) and the coccyx os
(tl.tungging).
In women, outside of pregnancy this articulation allows only a slight shift, but in pregnancy and delivery it can
shift further and more loosely, for example, the tip of the coccyx can move backward up to about 2.5 cm. This
can be done if the tip of the coccyx.
protrudes forward at delivery, and on expulsion of the fetal head with the cunam cunam the tip of the coccyx
can be pushed back. Functionally, the pelvis consists of two parts, namely the pelvis major and pelvis minor.
Major pelvis
is the part of the pelvis that is located above the linea terminalis, also called the false pelvis. The part that lies
below the linea terminalis is called the pelvis minor or true pelvis. In the space formed by the major pelvis,
 there are abdominal organs besides that the major pelvis is the place where the muscles and ligaments attach to
the body wall. Whereas in the space formed by the minor pelvis there are parts of the colon, rectum, bladder,
and in women there are the uterus and ovaries. In the pelvic space we also find the pelvic diaphragm which is
formed by the levatorani and coccygeal muscles.
a. Hip Size
1) Upper Pelvic Door
The upper door of the pelvis is formed by the promontorium of the corpus vertebrae of the sacrum, linea
innominata, and the upper edge of the symphysis. The diagonal conjugate is the distance from the lower edge
of the symphysis to the promontorium. Clinically, the diagonal conjugate can be measured by inserting the
closed index and middle fingers up the entire anterior surface of the sacrum, palpable promontorium as a bony
prominence. Keeping the fingers attached to the promontorium, the hand in the vagina is raised until it touches
the arcus pubis and is marked with the index finger of the left hand. The distance between the fingertips on the
promontorium to the point indicated by the index finger is the length of the diagonal conjugate.
Conjugata vera is the distance from the upper edge of the symphysis to the promontorium which is calculated
by subtracting the conjugate diagonalis by 1.5 cm, its length is approximately 11 cm. Obstetric conjugates are
the most important conjugates, namely the distance between the middle part of the symphysis and the
promontorium. The difference between conjugata vera and conjugata obstetrics is very small.
2) Middle Pelvic (Pelvic Cavity)
This pelvic chamber has the largest size. Clinical measurements of the mid-pelvis cannot be obtained directly.
There is a narrowing at the level of the ischial spine, so it is important in dystocia after head engagement. The
distance between the two spines, which is known as the interspinarum distancy, is the smallest pelvic distance,
which is 10.5 cm. The anteroposterior diameter at the height of the isciadic spine measures 11.5 cm. The
posterior sagittal diameter, the distance between the sacrum and the interspinarum diameter line is 4.5 cm. 3.4.
3) Lower Pelvic Door
The door below the pelvis is not a flat plane but consists of two triangles with the same base, namely the line
connecting the left and right ischial tubes. The pelvic gates that can be obtained through clinical measurement
are the distance between the two iscii tuberosity or tuberum (10.5 cm), the distance from the tip of the sacrum to
the middle of the tuberal dystia or posterior sagittal diameter (7.5 cm), and the distance between the edges.
below the symphysis to the end of the sacrum (11.5 cm).

4. Komplikasi
When labor with pelvic disproportionate phallos is allowed to take place alone when necessary. Taking
the right action, causing danger to the mother and the fetus (Sarwono)
1) Danger to mother
a. Prolonged labor, often accompanied by rupturing of the membranes at the small opening, can lead to
dehydration as well as acidosis and intrapartum infection.
b. With a firm, moderate progression of the fetus in a restrained birth canal, there can be stretching of
the lower segment of the uterus and the formation of a pathologic retraction loop (Bandl). This
condition is known as threatening uterine rupture. If measures are not taken to reduce the stretch
immediately, uterine rupture can result
c. With labor not progressing due to disproportionate pelvic cephalopods the birth canal is at one place
subject to prolonged pressure between the fetal head and the pelvis. This results in circulatory
 disturbances with consequent ischemia and subsequent necrosis at the site. Several days post partum
there will be cervical vesic fistula, or vesico vaginalis fistula or recto vaginalis fistula.
2) Harm to the fetus
a. Patuslama can increase perinatal mortality, if coupled with intrapartum infection
b. Prolasus Funikuli, if it occurs, is very dangerous to the fetus and requires childbirth if he is still alive.
c. With cephalopelvic disproportion the fetal head can pass through the pelvic barrier by means of
moulage which can be experienced by the fetal head without adverse consequences to some extent.
However, if these limits are exceeded, tearing of the tentorium cerebelli and intracrahial bleeding
occurs
d. Subsequently pressure by the promontorium or sometimes by symfiction in the hip fracture causes
injury to the tissue above the fetal skull

5. Management
a. Trial Labor
After assessing the size of the pelvis and the relationship between the head of the fetus and the pelvis, it
can be estimated that the delivery can take place vaginally safely, then trial delivery. This method is a
test of his strength, accommodation capacity, including moulage because these factors cannot be
known before delivery.
Experimental labor is only performed on the back of the head, not in the breech position, forehead
position, face position, or other location abnormalities. Another rule is that the gestational age should
not be more than 42 weeks because the fetal head is enlarged so that it is difficult to moulage and there
is the possibility that fetal placental dysfunction will complicate trial delivery.
In a large fetus, difficulties in bearing the shoulder cannot always be predicted beforehand. If during the
birth process the baby's head has come out while the delivery of the shoulder is difficult, it is better if a
sufficiently wide medioateral episiotomy is carried out, then the nose and mouth of the fetus are
cleaned, the head is pulled steeply downward carefully and of course with measured force. If this does
not work, you can rotate the baby's body in the pelvic cavity, so that it becomes the front shoulder
which was previously the rear shoulder and is born under the symphysis. If this method still does not
work, the helper inserts his hand into the vagina, and tries to deliver the fetus by moving his chest in
front. To deliver the left arm, the helper uses his right hand, and vice versa. Then the front shoulders
are turned to the oblique diameter of the pelvis to give birth to the front shoulders.
There are two kinds of trial labor, namely trial of labor and test of labor. The trial of labor is similar to
the trial labor above, whereas the test of labor is actually the final phase of the trial of labor because it
only starts at complete opening and ends 2 hours later. Currently the test of labor is rarely used
because it is usually incomplete opening in a narrow-hump labor and there is a high mortality of
children in this way.
The success of the trial delivery is that the child can be born by vaginal birth or assisted with extraction
with the condition of the mother and child both. Trial labor is terminated if the opening is not
progressing or not, the condition of the mother or child is not good, there is a bandl circle, after
complete opening and rupture of the head does not enter PAP within 2 hours even though his is good,
as well as in failed forceps. In this situation a cesarean section is performed.
b. Sesarea Section

Elective cesarean section is performed in severe pelvic narrowing with term pregnancy, or marked
sephalopelvic disproportion. Section can also be performed on mild pelvic stagnation if there are
complications such as old primigravida and irreparable fetal positioning.
Secondary cesarean section (after delivery for a period of time) was performed because trial delivery was
considered a failure or there was an indication for completion of labor as soon as possible while the
requirements for vaginal delivery had not been met.
c. Symphisiotomy
This action is performed by separating the left and right pelvis at the symphysis. This action is not done
anymore.
d. Craniotomy and Kleidotomy
In fetuses that have died can be done craniotomy or kleidotomy. If the pelvis is so narrow that the fetus
cannot be delivered, cesarean section is performed.
Actually the pelvis is only one of the factors that determine whether the child can be born spontaneously
or not, in addition to many other factors that play a role in the prognosis of labor. If the conjugata vera
is 11 cm, it can be ascertained that normal labor, and if there is difficulty in labor, it is definitely not
caused by pelvic factors. For CV less than 8.5 cm and full-term children it is impossible to pass the
pelvis.
1) CV 8.5 - 10 cm is subject to trial delivery which may end in spontaneous delivery or by vacuum
extraction, or is helped by secondary caesarean section for other obstetric indications
2) CV = 6 -8.5 cm performed primary SC
3) CV = 6 cm performed absolute primary SC.
Besides the things mentioned above also depends on:
a. His or energy that drives the child.
b. Fetal size, presentation and fetal position
c. Hip shape
d. The age of mother and child is precious
e. Mother's disease

6. Supporting Examination
1) Radrology Examination
For Pelvimetry, 2 photographs were made
a. Photo of the upper doorway
The mother is in a half-sitting position (Thoms), so that the X-ray tube is perpendicular to the upper
pelvis
b. Lateral photo
The mother is in a standing position, the X-ray tube is directed horizontally against the side virtual
trochanter
7. Nursing Diagnosis
1) Lack of knowledge related to inadequate information about the care procedures before and after
delivery through SC surgery
2) High risk of injury related to physiological function and tissue injury.
3) Anxiety associated with threats to self-concept.
4) Situational low self-esteem is associated with feeling a failure in life.

8. Nursing Care Planning

1)
Dx: Lack of knowledge related to lack of information about procedures and prenatal care through SC surgery.
Destination :
Clients can understand about the delivery procedure via SC and are willing to cooperate in pre-surgical
preparation
Result Criteria:
a. The client understands the procedure for delivery via SC
b. The client is willing to cooperate in pre-surgical preparation.
Intervention:
a. Discuss with clients and loved ones the reasons for SC.
b. Describe the preoperative procedure and the possible risks that can occur (Informed Consent).
c. Testify in the process of signing an action agreement.
d. Get basic vital signs.
e. Collaboration in Lab testing. (DPL, electrolytes, blood group and urine).
2) Dx: High risk of injury related to physiological function and tissue injury.
Destination:
High risk of injury and injury does not occur.
Result Criteria:
Clients are able to implement behaviors to reduce the risk of injury and self-protection so that they can be free
from complications.
Intervention:
a. Observe vital signs.
b. Observe dressings for excessive bleeding.
c. Pay attention to the catheter, number of lochia and consistency of the fundus.
d. Monitor fluid intake and urine output.
e. Encourage foot / ankle exercises and early ambulation.
f. Instruct clients to always change body position (sitting, lying in a flat position).
g. Observe the surgical wound area (whether there has been a change in the direction of healing or signs of
infection).
h. Observe the lower limb area for signs of thromboplebitis
i. Give intravenous fluids according to the program.
j. Check Hb, Ht postoperatively compare with preoperative levels.

3) Dx: Anxiety related to threats to self-concept.

Purpose: Anxious does not occur.
Result criteria:
a. The client understands, understands and is able to express anxiety and is able to identify ways to reduce the
level or eliminate anxiety independently.
b. The client says that anxiety is under control and is in a state that can be managed.
c. The client looks relaxed and can sleep and rest enough.
Intervention:
a. Encourage clients to express feelings.
b. Help clients identify common coping mechanisms and develop coping strategies as needed.
c. Provide accurate information abonew the condition of the client and the baby.
d. Instruct the client to frequent contact with the baby as soon as possible.
4) Dx: Situational low self-esteem is associated with feeling a failure in life.
Destination:
Feelings of situational low self-esteem do not occur.
Result criteria:
a. Clients are able to discuss problems related to roles and perceptions of birth experiences
b. Client or partner and able to express positive self-expectations.
Intervention:
a. Determine the client's emotional response or preference to the SC birth.
b. Review participation and role of client / partner in the birth experience.
c. Tell the client about the similarities between CS and vaginal delivery.

DAFTAR PUSTAKA

Prawirohardjo, Sarwono. 2002. Ilmu Kebidanan. Jakarta: Yayasan Bina Pustaka Sarwono
Prawirohardjo
Saifuddin AB. Ilmu Kebidanan Sarwono Prawirohardjo. Edisi Keempat. Jakarta: BP-SP, 2008.
Diambil di http://aangcoy13.blogspot.com/2012/05/askep-cephalopelvic-disproportion-cpd.html pada
tanggal 24 Oktobel 2014 pukul 14.00 WITA
Diambil di http://rumahkitabro.blogspot.com/2010/11/asuhan-keperawatan-cephalo-pelvik.html pada
tanggal 24 Oktobel 2014 pukul 14.00 WITA

Banjarmasin, 8 Feberuari 2021

College student

Nadia Tara Dila

NPM. 1914201310078

To agree

Clinical Advisor Academic Advisor

 Nurhikmah, S.Kep.,Ns Esme Anggraini, Ns.,M.Kep
NIP. 1096 NIDN. 1131129002

Student name : Nadia Tara Dila

NPM : 1914201310078
Room :-
NO Day/ Consul Material Feedback / Suggestions TTD Clinical
Date Advisor
Jum'at , 5 Report -change the report by lenguange
februari CEPHALOPEL - looking for the new reverance,
2020 VIC up 2018
- arrange words and sentences
DISPRORTION properly
(CPD)
Nama : Nadia Tara Dila

NPM : 1914201310078

PRENERS 3

ASSESSMENT FORMAT OF PRENATAL NURSING PROGRAM

STUDY OF NURSING PROFESSIONAL NERS FACULTY OF
NURSING AND HEALTH SCIENCE UNIVERSITY
MUHAMMADIYAH BANJARMASIN

Date of entry:28 januari 2021 Hours of entry : 12.400 WITA

Classroom : Al biruni Room : 704

Review date:2 Februari 2021 time : 14.30 WITA

1 Identitas
1.1 Name : Ny. Siti Rahimah Name :M. sabirin
husband
1.2 age : Age :
1.3 Nation : indonesia Nation : indonesia
1.4 Religion : islam religion : islam
1.5 Education : Senior High School Education : Senior High
School
1.6 work : Work :
1.7 Address : gg. soraja Address : Gg. soraja

Medical
history
Main complaint:
feeling anxious about giving birth to twins

Current medical history:

- the patient delivers the first child
Past medical history:
the patient had no past history
 Family health history :
Nothing

Obstetric history
Menstrual history
Menarche age: -
Cycle: regular () irregular ()
Duration: -
Student complaint: -
Contraceptive History
Contraception: Hormonal () IUD / IUD () Tubectomy () Natural () natural using tools () No
()
Old Usage: -
Complaints: -History of past pregnancy and childbirth
No Years Place Helper Labor UK JK BBL H/M

Current pregnancy history

Obstetric status: G3 P2 A1
HPHT: 5- 5- 2020
HPL: -
BB before pregnancy: 65 Kg BP before pregnancy: -
Immunization TT: No, if yes how many times: -
 The Physical Examination and Assessment of Gordon

Perceptions of pregnancy and health management during pregnancy: (assumptions about

the PREGNANCY process in patients)
After learning about the twin pregnancy, the mother was anxious about having a second
cesarean delivery
Cognitive and perceptual
No evailable
Self-perception and self-concept
No evailable
Roles and relationships :
No evailable
Sexuality and reproduction:
No evailable
Coping and stress mechanisms :
(Habits that are carried out when experiencing health problems)
No evailable

Values and beliefs about pregnancy:

(The values that are believed and carried out when having health problems by patients,
families and communities. To the extent that the names of these belief values affect
health behavior)
No evailable

Acceptance of pregnancy:
No evailable
 Head neck:
Hair : -
Nose : -
Mouth : -
Ear : -
Neck : -
Chest
Heart :-
Lung :-
Breast :-

Putting susu : Pengeluaran ASI

Inverted
Ada

Datar
Tidak

oMenonjol :

Abdomenn
TFU: - cm Contraction: Yes / No
LeopodI: Head / Butt / Empty
 LeopodII: Right: Back / Small part / Butt / Head LeopodIII: Head / Butt / Empty
: Decreased head: Already / Not Leopod IV: Part of LAP entry ………………
Pigmentation:
Lineanigra: ……………………………………………………… ..
Striae: ……………………………………………………………
Scar (surgical scar): …………………………………………….
Digestive function: ……………………………………………………..

Nutrition and Fluids

Nafsumakan: Good / Less / Nothing
Anthropometry: BW 90 Kg TB - cm
Biochemical: -
Clinis: -
Report on food intake for the last 2 - 3 days (no data)
Liquid intake: a day ……… .ml enough / less

Rest and comfort

Sleep patterns: sleep habits, length of… hours, frequency
…………………………………………………………………… ............... Current sleep pattern: -
Sleep disturbance: -

Mobilization and Exercise

Mobilization rate: -
Gymnastics : -

.
Extremities
Varieses: Yes / No
Edema: Yes / No
Reflexpatella: 0 / + 1 / + 2 / + 3 / + 4

.
Perineum and Genital
Vagina: Varicose veins: Yes / No.
Cleanliness: -
Whitish: -
Color: -
Consistency: -
Smell : -
Hemorrhoid (anus): Yes / No
 Elimination
Urine: …… / day Volume: …………………….
CHAPTER: constipation: Yes / No
Consistency: / day

Results of Supporting Ultrasound / X-rays

The results of ultrasound examination showed the pregnancy of male and female twins

Therapy
Dose Rasional
Medici
ane
Infus RL 20 tpm - To prevent lack of fluid volume
Injeksi 2 gr pre opTo inhibit bacterial growth or kill bacteria
ceftriaxone

7.Analisis data
PROBLEM ETIOLOGI
NO DATA
NURSING
 1 DS :
After knowing Ansietas Threats at current
Multiple pregnancy status
patients are anxious
in the face of a
second cesarean
delivery.
DO :
The patient looks
worried
The patient's face
looked worried
TTV:
TD: 155/98
Pulse: 146 x / minute
Temperature: 36.5
ºC
Inhalation: 23 x
minutes
Spo2: 99%
USG: Gameli

Priority for Diagnosis of Nursing

Nursing Planning

NO No Diagnosa Nursing Outcome Nursing Intervention Rasional

diag.
kep
1 00256 Anxiety b.d After nursing care 1 x 24 hours Calming Technique
Threats at
current status with calming techniques, Maintain a calm and
careful attitude
emotional support Reduce stimuli that So that clients want to
create feelings of fear be open
Result criteria: Prevent anxiety from
or anxiety
Be on the client side getting worse
NOC
Give yourself time To be there when the
1.Anxiety level (distress and space to be alone client needs it
if needed So that clients can
maintained at 2 increased to 4) Give anti-anxiety calm down
medication if needed To relieve anxiety
2. Coping (reported stress

reduction maintained at 4 Emotional Support

Emotional Support So that clients can open
increased at 2) up
So that the level of
3. Environmental comfort status Discuss with the
anxiety in the patient is
(peaceful environment maintained patient about [his] reduced
To relieve anxiety
at 2 increases to 4) emotional experiences.

Stay with the patient

and provide assurance

of safety and security

during periods of

anxiety

Embrace or touch the

patient with support

 Banjarmasin, 6 Februari 2021

Preseptor akademik, Preseptor Klinik

(Nur Hikmah, S.Kep.,Ns) (Esme Anggraini, Ns., M.Kep)

 LEMBAR KONSUL PEMBIMBING AKADEMIK

Nama Mahasiswa : Nadia Tara Dila

NPM : 1914201310078
Ruangan
NO Hari/ Materi Masukan /Saran TTD Pembimbing
Konsul Akademik
Tanggal
 Nursing Care HEG
Hiperemesis Gravidarium
To fulfill the task of maternity nursing clinic practice 1

Name : Nadia Tara Dila

NPM : 1914201310078
Semester : III
Hospital : Islam Banjarmasin
Group : 2 Bilingual
Clinical Advisor :Nurhikmah, S.Kep.,Ns
Academic counselors : Esme Anggeriyane, Ns.,M.Kep

BILINGUAL NURSING STUDY PROGRAM

FACULTY OF NURSING AND HEALTH SCIENCE
MUHAMMADIYAH BANJARMASIN UNIVERSITY
2020-2021
ASSESSMENT OF PRENATAL NURSING PROGRAM STUDY
PROGRAM NERS PROFESSION NERS FACULTY OF NURSING
AND HEALTH SCIENCE MUHAMMADIYAH BANJARMASIN
UNIVERSITY
Date of entry: 7 February 2021 Hours of entry : 13.00 WITA

Room : IGD RS Islam Class :-

Assessment date: 7 February 2021 Time : 13.00 WITA

1.1 Client Name : Ny. M Husband : Tn. T
Name
1.2 Age : 25 tahun Age : 25 tahun
1.3 nation : Indonesia Nation : Banjar
1.4 Religion : Islam Religion : Islam
1.5 Education : SMA education : SMA
1.6 Jobs : Ibu rumah tangga Jobs : Wiraswasta
Medical
history
Main complaint:
Starting from 6 - 7 February 2021 the patient complained of nausea and frequent vomiting,
decreased appetite, nausea was felt when he smelled food and vomited when eating
nutritional intake (consuming rice), complaints were reduced if the patient did not eat and
rested in bed, the patient too complained of epigastric pain, intermittent pain with a duration
of 7-8 minutes and was like being stabbed, pain appeared with a pain scale of 4 (0-10),
anxious about her condition and her baby.
Current medical history:
The patient was diagnosed with G2P1A0, 6 weeks pregnant, nausea and vomiting
frequently for 2 days, decreased appetite, nausea was felt when the patient smelled the smell
of food and vomited when eating nutritional intake (consumed rice), complaints were
reduced if the patient did not eat and rest in place sleep, the patient also complained of
epigastric pain, pain intermittent with a duration of 7-8 minutes and like stabbing, pain
occurs with a pain scale of 4 (0-10). On physical examination, the patient looks weak, the
mouth is dry, the patient's face sometimes grimaces, the eyes are sunken, the skin turgor is
not elastic, the patient also says that he is worried about his condition and is worried about
the condition of the baby.
 family medical history:
The patient said he did not have a genetic disease.

Obstetric history
Menstrual history
Menarche age: 14 years
Cycle: regular
Duration: 7 days
Complaints during menstruation: No complaints
History of contraception
Contraception: Hormonal
Duration of use: 1 month
Complaints: None
Past history of pregnancy and childbirth
 1 2019 RS Islam Midwife Normal 39 M LK 3,1 kg Normal/
Nothing
Problem

Current pregnancy history

Obstetric status: G2P1A0
HPHT: January 1, 2021
HPL: February 7, 2021
BW before pregnancy: 50 Kg BP before pregnancy: 123/80 mmHg
Immunization TT: Yes, if yes how many times: 1 time
Physical Examination and Gordon's Assessment
Perceptions of pregnancy and health management during pregnancy: (assumptions about
the PREGNANCY process experienced by patients)
-
Cognitive and perceptual
-
Self-perception and self-concept
-
Roles and relationships:
-
Sexuality and reproduction:
The patient complains of epigastric pain
Coping and stress mechanisms:
Not eating and resting in bed
Values and beliefs about pregnancy:
(Values that are believed and carried out when having health problems by patients,
families and communities. To the extent that the names of these belief values affect health
behavior)
-
Acceptance of pregnancy:
The patient feels anxious about the condition of the baby
Nutrition and Fluids
Nafsumakan: Less
Anthropometry: weight 43 kg TB - cm
Biochemical: -
Clinis: -
Report on food intake for the last 2 - 3 days
Fluid intake: 400 ml less a day

Rest and comfort

Sleep pattern: sleep habits, duration, 8 hours, frequency
Current sleep patterns: approximately 5 hours a day
Sleep disturbance: Pain

Mobilization and Exercise

Mobilization rate: -
Gymnastics :-

Extremities
Varieses: -
Edema: -
Reflexpatella: -

Perineum and Genital

Vagina: Varicose veins: -
Cleanliness: -
Whitish: -
Color: -
Consistency: -
Smell : -
Hemorrhoid (anus): -
Elimination
Urine :- Volume : -
BAB : konstipasi : -
Konsistensi: : -

Results of Supporting Ultrasound / X-rays

-

Therapy
Drug Dose Rational

- - -

7.Analisis data
Nursing Problem ETIOLOGI
NO DATA
1 SD : Decreased urination Loss of fluid due to
Px complained of vomiting and inadequate
nausea and vomiting fluid intake
frequently during these
2 days
Px complains of
decreased appetite,
nausea is felt when the
patient smells the
smell of cooking and
vomits when eating
nutritional intake,
complaints are reduced
if the patient does not
eat and rest in bed,

OD :
Px looks limp, dry
mouth, sunken eyes
the patient's face
sometimes grimaces,
the skin turgor is not
elastic
TD: 110 / 60mmHg
N: 100x / min
R: 20x / min,
T: 36.6 ° C
BB 43 kg
2 SD: Pregnancy
Nausea
 Px complains of
decreased appetite,
nausea is felt when the
patient smells the
smell of cooking and
vomits when eating
nutritional intake,
complaints are reduced
if the patient does not
eat and rest in bed,
OD :
Px looks limp, dry
mouth, sunken eyes
the patient's face
sometimes grimaces,
the skin turgor is not
elastic
TD: 110 / 60mmHg
N: 100x / min
R: 20x / min,
T: 36.6 ° C
BB 43 kg
3 SD : Acute pain Repeated vomiting
Px complained of
epigastric pain,
intermittent pain with a
duration of 7-8
minutes and like
stabbing, pain occurs
with a pain scale of 4
(0-10).

P: Pain
Q: Pain like being
stabbed
R: Pain focuses on the
patient's epigastrium
S: Pain scale 4 (0-10)
Q: It's been 2 days
from 6 - 7 February

OD :
Px looks limp, dry
mouth, sunken eyes
the patient's face
sometimes grimaces,
the skin turgor is not
elastic
TD: 110 / 60mmHg
N: 100x / min
R: 20x / min,
 T: 36.6 ° C
BB 43 kg
4 SD : Fright Effects of hyperemesis
Px was anxious about on fetal well-being
his situation and
anxious about the
condition of his baby

OD :
Px looks limp, the
patient's face
sometimes grimaces
Px looks worried

Nursing Diagnosis Priority

Fluid volume deficit b.d loss of fluids due to vomiting and inadequate fluid intake
Nausea b.d pregnancy
Chronic pain b.d repeated vomiting
Fear b.d hyperemesis effect on fetal well-being

Nursing Planning
1 00027 Fluid volume Result Criteria: Assess fluid intake
deficit b.d loss The fluid and output status This assessment
of fluids due balance Weigh BB every day forms the basis for
to vomiting returns Give intravenous the insurance plan
and to fluids consisting of and intervention
inadequate normal glucose, electrolytes evaluation
fluid intake The client and vitamins Observe the level of
consume Instruct clients to fluid intake every day
s consume oral fluids To prevent
adequate slowly dehydration and
amounts Instruct the patient to improve acid-base
of food eat nutritious foods balance
and To increase fluid
drink intake
The client To improve health
doesn't
vomit
anymore

2 00076 Nausea b.d Result Criteria:

pregnancy Patients can Perform a To get more complete
well complete data about the
avoid assessme patient's disease
the nt of
To find out the effect
causativ nausea
e factors includin of disease on patient
of g gaps
nausea frequenc To increase fluid
Patients take y, intake
acupress duration, Not to be nauseous
ure point degree and vomiting
P6 to of
To reduce nausea
prevent nausea,
and Therapy to reduce
nausea
relief factors nausea
causing To reduce vomiting
the and make calm
patient
to be
nauseous
.
Evaluate
the
effect of
nausea
on the
patient's
 appetite,
daily
activitie
s, and
sleep
patterns
Encourage
small,
frequent
and
warm
meals
Instruct
patient
to
reduce
the
amount
of food
that can
cause
nausea.
Provide
adequat
e rest
and
sleep
Perform
acupress
ure
point P6
3 fingers
under
the
patient's
wrist.
Do it for
2-3
minutes
every 2
hours
during
chemoth
erapy.

Collabor
ative
antiemet
ic
 administ
ration:
ondanse
ntron 4
mg IV if
nauseal

3 00133 Chronic pain Result Criteria:

b.d repeated A sense of Assess pain level To determine the
vomiting comfort is Adjust the position with level of pain and
fulfilled your head elevated for determine the next
30 minutes after eating plan of action
Divert the client's To reduce pressure
attention to fun things on the
Instruct clients to gastrointestinal tract
consume ginger (in the To forget pain
form of ginger tea) and to reduce nausea and
mint flavored candy. vomiting in pregnant
Collaboration in women
providing antiemetic and Reduces vomiting
sedative and calms down
thereby reducing pain

4 00337 Fear b.d Result Criteria:

effects of The client will Show acceptance of the acceptance of the
hyperemesis express his client's fear client's fear allows
on fetal well- feelings and Encourage clients to open communication
being concerns about express feelings and it is feared that it
the well-being of concerns will have a negative
the fetus Assist clients in impact on the
identifying their own condition of the fetus
strengths and coping needed to increase
mechanisms the client's ability to
Give the client cope with the disease
information about the and its effects
potential risks that can knowledge of the
occur to the fetus potential risks to the
Maintain an open fetus can help to
attitude towards client dispel fear
beliefs Acceptance is
important for
developing and
maintaining a
relationship
 Banjarmasin, 11 Feberuari 2021

Mahasiswa

Nadia Tara Dila

NPM. 1914201310078

Menyetujui

Clinical Advisor Academic counselors

Nurhikmah, S.Kep.,Ns Esme Anggeriyane, Ns.,M.Kep

NIP. 1096 NIDN. 1131129002