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CASE REPORT

NURSING CARE Mrs. N WITH


PARTUS VACUUM EKSTRANSI IN OBSTETRIC ROOM
(B3O) RSUP Dr. KARIADI SEMARANG

Disusun Oleh :
Nurul Maulifathul Jannah

CENTRAL JAVA GOVERNMENT


NURSING ACADEMY
2010

CASE REPORT
NURSING CARE Mrs. N WITH
PARTUS VACUM EKSTRANSI IN ROOM OBSTETRI (B3O) RSUP Dr. KARIADI
SEMARANG
Assessment Date : 15th March 2010
Study Hours : 15.00 WIB
Room : B3O (Obstetric)

I. BIODATA
a. Patient Identity
Name : Mrs. N
Age : 26 years old
Sex : Female
Tribe / Nation : Java / Indonesia
Religion : Islam
Education : Senior High School
Occupation : Entrepreneur
Address : Kebonharjo, Tanjung Mas Rt 16/05 Semarang Utara
Date Admitted : 14th march 2010
Medical Diagnosis : DEEP TRANVEKSIS ARRET
Husband : Mr. S
Occupation : Entrepreneur
Age : 31 years old
Religion : Islam
Education : STM

II. NURSING HISTORY


a. Present nursing history
Patient came to the hospital because she was felt contraction on March 14 th,
2010 and her membrane was broken. Patient was born a child in VK room with
vacuum extraction because there is a difficulty in “kala 2”. Patient said that she
doesn’t want to have a child again because she felt fear that similar incident will
happen for next childbirth. Today is second day after birth her baby. Patient condition
is good now, patient can walking around now but she complained her breasts were
swollen and painful on her vagina when urinate.
b. Obstetric history
1) Menstrual/ Period History
Patient first time get period when 15 years old, regular 28 days cycles of
period and 7 days when get period. HPHT 6th juny 2009.
2) Pregnancy History
Patient said that it’s her first pregnancy, 4 times for ANC and get TT
immunization one time. She also consumes Fe tablets three times a day during
pregnancy. Baby birth is done with vacuum extraction, baby birth weight is
2900 grams, body length 48 centimeters, head circumference 35 centimeters,
chest circumference 32 centimeters.
c. Family Planning History
The patient did not carry out family planning but she has plans to use KB
injection after her baby birth.
d. Past Nursing History
Previously, patient only have a fever, cough, influenza and cold
e. Family Nursing History
Patient said that there’s no hereditary disease in her family such as DM,
hypertension, heart disease, asthma.

III. FUNCTIONAL PATTERNS


a. Pattern of nutrition and metabolic
Patient said that she eating 3 times a day, good of appetite, she also eat a lot of
vegetables and fruits. During the pregnant patient consume “PRENAGEN” twice a
day.
b. Pattern of Elimination
Patient said that she urinate ±6 times a day, yellow color, she’s also complain
when urinating.
P : when urinate
Q : sore
R : on the pubic area
S : scale 5
T : pain when urinate (intermittent)
Bowel elimination one time a day, yellow color, typical aroma, soft
consistency. During 3rd semester of pregnancy she started having hard bowel
elimination.
c. Pattern of Personal Hygiene
Patient said that she take a bath twice a day. Oral hygiene twice a day.
d. Pattern of Rest and Sleep
Patient said that she sleep for 7 hours a day but she often wake up and make
her can’t sleep well, that caused by her baby crying.
e. Pattern of Activity and Exercise
Patient said that she still do her task as a wife. She also walks around in the
morning during pregnancy. Now, she still can do anything independently such as eat,
toileting, personal hygiene, etc.
f. Pattern of habit that affect health
Patient said that she’s not a cigarette, alcohol or drugs consumer.
g. Psychosocial History
Patient looks very happy and pleased with her baby birth. Patient family also
very pleased. Patient said that she was ready to be a mother mentally and physically.
Now, patient was on “taking hold” phase because she able to interact with her baby.
Patient already know about perineum care, nutrition and KB. But, patient didn’t know
about breastfeeding technique and breast care. She’s look confused when asked.
IV. PHYSICAL EXAMINATION
1. General condition : Good
2. Level of consciousness : Compos mentis
3. Vital signs : BP : 120//70mmHg
Temp : 36.5°C
RR : 16 times/min regularly
Pulse : 64 times/min regularly
4. Sight system
Symmetric eye position, normal eyelid, normal eye movements, red conjunctiva,
normal cornea, unikterik sclera.
5. Respiratory system
Clean airway, no shortness of breath, regular rhythm, shallow, no cough, vesicular
breath sounds, and no additional breath sounds.
6. Cardiovascular system
Pulse 64times/min, regular rhythm. BP: 120/70 mmHg. No jugulars vein distension.
Warm skin temperature, redness skin color. Capillary refill <2 seconds. No edema.
Irregular heart rhythm, normal heart sounds, no chest pain.
7. Digestive system
Condition of mouth: no caries, no stomatitis, clean tongue
No vomiting, bowel sounds 15 times/min, convex abdomen. The liver was not
palpable.
8. Hematology System
Hb : 10,6 g%
Leukocyte : 17.700 thousand/mmk
Trombocyte : 283 thousand/mmk
9. Endocrine system
Breath does not smell of ketones.
10. Uro - Ana Genital system
Patient already urinates, 6 times a day. Total 800cc a day. Clear yellow color, there
was pain when urinate, no pain on her waist. There are mediolateral episiotomy
wound on her perineum.

REEDA signs
R : No redness
E : No red spots
E : No edema
D : lochea: alba
A : the wound still opened

11. Integument/ musculoskeletal system


Skin turgor less than 2 seconds, the reddish skin color, good skin condition, clean.
No contractures, symmetrical limb extremities. No edema and varices. No
tromboplebitis (Hotman sign doesn’t exist).
12. Breast
Enlarged mammary, there was pain when palpable
P : pain felt when the breast in the grasp
Q : senut-senut
R : on her breast
S : scale 4
T : periodic (intermitten)
black areola, right mammary papilla inverted, colostrums out,
13. Abdomen
TFU: 2 fingers below the center, strong contractions, fully urinary gallbladder. There
are linea nigra and striae.
V. EXAMINATION SUPPORT
Therapy
Asam Mefenamat 3 x 500mg PO
Vitamin B complex 2x1 PO
Vitamin C 2x1 PO
Vitamin K 2x1 PO

VI. PROBLEM LIST


Name : Mrs. N
Age : 26 years old
No Date/ Time Focus Data Problem Etiology Sign
1 Monday, 15 SD : Defisit of Defisit of
March 2010
- Patient say her breast knowledge information
16:00 pm not produce milk yet about about
- Patient said she’s not yet breastfeedin breastfeeding
can do breast care g and breast and breast
OD: care care
- Inverted right nipple techniques techniques
- Incorrect breastfeeding
technique
- Patient looks confused
when asked about breast
care.
2 Monday, 15 SD: Risk for Port of entry
March 2010 Patient said that she felt infection microorganis
16:05 pm pain when urinate ms secondary
OD: with post
- There are mediolateral episiotomy
episiotomy wound wound
R : No redness
E : No red spots
E : No edema
D : lochea: alba
A : the wound still opened

3 Monday, 15 SD : Acute pain Swelling of


March 2010 Patient said pain the breasts
16:10 pm P : pain felt when the and there are
breast pressed wounds on
Q : senut-senut
the perineum
R : on her breast
S : scale 4
T : periodic (intermittent)
Patient also said pain in
P : when urinate
Q : sore
R : on the pubic area
S : scale 5
T : pain when urinate
(intermittent)
OD :
- Patient seen wincing
when the breast pressed.
- Enlarged mammary
Problem Priority:
1. Comfortable disturbances: pain r.t swelling of the breasts and there are wounds on the
perineum
2. High risk of infection r.t port of entry microorganisms secondary with post episiotomy
wound
3. Lack of knowledge about breastfeeding and breast care techniques r.t Lack of
information about breastfeeding and breast care techniques

VII. NURSING CARE PLAN


NO Date /time Nurse diagnose Purpose Intervention Sign
1 15 March Acute pain r.t After the nursing 1. Teach relaxation
2010 swelling of the
action during 2 x and distraxion
breasts and
16:15 pm there are 24hours, the pain of technique
wounds on the
patients will decrease 2. Give a
perineum
with outcome criteria: comfortable
- Patients can adapt to environment
the pain 3. Give analgesics
- Pain scale was drugs
reduced to 1 4. Do warm
- Swelling breast can compress
reduce 5. Ask the patient if
the breast is still
swollen
2 15 March Risk for After doing the 1. Help the patient
infection r.t
2010 nursing actions during to maintain the
port of entry
16:20 AM microorganisms 2x24hours high risk of cleanliness of the
secondary with
infection does not perineum
post episiotomy
wound occur in patients with 2. Do vulva hygiene
outcome criteria: 3. Instruct the
1. Dry wounds patient to always
2. No infection signs maintain the
cleanliness of the
genital area
4. Give BC, C and K
vitamin
3 15 March Defisit of After doing nursing 1. Teach about
2010
knowledge action during 2 x 2 breastfeeding
16:25 pm about hours patient expected technique
breastfeeding to know about breast 2. Teach about
and breast care care with outcome breast care
techniques r.t criteria: technique
Defisit 1. Patient able to 3. Discuss about
information answer everything breast care
about about breast care 4. Explain about
breastfeeding 2. Patient able to re- benefits of breast
and breast care demonstrate breast care
techniques care technique 5. Demonstrate
about breast care
technique
6. Instruct patient to
re-demonstrate
breast feeding
technique
VIII. NURSING NOTE
Name : Mrs. N
Age : 26 years old
NO Time /date Nursing diagnose Implementation Responds Ttd
1 15 March Acute pain r.t 1. Teaching SD:Patient want to
2010 swelling of the
relaxation and try
16.40 breasts and there
are wounds on the distraxion OD:Patient look
perineum
technique calm
2. Giving asam DO: Patient drink it
17.05
mefenamat 1
tablet PO
3. Doing warm DS: Patient said
17.10
compress that she felt
comfortable right
now
2. 15 March Risk for infection 1. Instructing the Patient want to do
2010 r.t port of entry
patient to it
16.10 microorganisms
secondary with post always maintain
episiotomy wound
the cleanliness
of the genital
area
16 March 1. Doing vulva 1. Patient agree to
2010 hygiene do it, clean
8.00 am wound
8.10 am 2. Help the patient 2. Patient want to
to maintain the do it, clean
cleanliness of perineum
the perineum
8.15 am 3. Giving BC, C, 3. Patient drink the
K vitamins @ 1 vitamin
tablet
10.00 4. Vital signs
4. BP:
monitoring
120/70mmHg
Pulse: 70
times/min
Temp.: 36.7°C
3 16 March Defisit of 1. Teaching about 1. Patient know
2010
knowledge about breastfeeding how to
09.00 breastfeeding and technique breastfeeding
breast care 2. Teaching about
09.40
techniques r.t breast care 2. Patient followed
Defisit information technique the istructions
10.10 about breastfeeding 3. Instructing 3. Patient can do it
and breast care patient to re- independently
techniques demonstrate
breast feeding
technique

XI EVALUATION
Name : Mrs. N
Age : 26 years old
Date/ Time Nursing Progress Note Sign
diagnoses
March, 16th, Comfortable S : Patient said that her breast wasn’t felt pain
2010 09.00 disturbances: pain after compressed and she also can adapt
r.t swelling of the with her pain now
breasts and there O : Patient looks relax
are wounds on the A : Problem resolved in part
perineum P : Suggest the patient to coompress her
breast with warm water in the morning
and afternoon

March, High risk of S: -


16th, 2010 infection r.t port O : wound condition still wet, clean, no
10.05 of entry redness, no
microorganisms A : Problem resolved in part
secondary with P : Suggest the patient to keep clean her
post episiotomy perineum after urinate/ bowel elimination
wound
and change her pads regularly

March, Defisit of S : Patient said that she already know about


17th, 2010 knowledge about breastfeeding and breast care technique
09.10 O : - Correct position of breastfeeding
breastfeeding and - Patient can re-demonstrate breast care
breast care technique
A : Problem resolved
techniques r.t P : Discuss about baby care at home
Defisit
information about
breastfeeding and
breast care
techniques