NURSING IN NY.

S POST
SC WITH disproportion
HEAD HIP (DKP)

1. Danik Setyo Wahyuningrum

2. Dwi Mustikawati
3. Ika Dwi Rachmawati
4. Kharisma Agustina
5. Liota Marsha Renardiyanto
Case Scenario:

Mrs. S, aged 27 years old was a postoperative sectio

caesarean patient on the 3rd day with "Pelvic Head
Disproportion" (narrow pelvis) DPK on July 25, 2016.
The nurse received data with the main complaint that
the dressing had not been replaced for 3 days and the
patient said that she did not know what food could be
eaten after SC surgery. During the assessment, the
patient's data is scheduled to go home
A. GENERAL CLIENT DATA

a. Initial client : Ny.S

b. Age : 27 years
c. Marital status : married
d. Job : farmer
e. Last education : SD
f. Address : Mandiarjo, Bantean, Kendal
g. Initial husband : Mr. Ag
h. Age : 31 year
i. Occupation : farmer
j. Last education : SD
k. Address : Mandiarjo, Bantean, Kendal
B. HEALTH HISTORY
1. History of past pregnancy and childbirth
a. History Obstetrics: G3P2A1 HPT: 18/10/15 HPL: 25/7/16
– Age at first marriage: 25 years
– Marriage to: 2
b. reproduction
–Menarche: 12 years
–Menstrual cycle: 30 days long 7 days
–Menstrual problems: desminore
2. Main complaints
Patients say bandage the injury to the former is uncomfortable because it has not been replaced for 3 days
3. Nursing complaints now
Post op patients Taste the day of the SC when the assessment was done said there were no complaints, the patient was bused a breastfeeding and
bathing, dressing has not been replaced
4. Health / pregnancy history now
– Several times have a pregnancy check: 5X in BPM and 2X in a doctor for ultrasound
– Pregnancy problems: DKP, ever abortion at 3 months gestation
C. GENERAL DATA OF HEALTH CURRENT

1. General Conditions : Good 4. chest

Awareness : chomposmentis Heart: I : ICs do not appear on IC4 &
2. Vital Signs : TD: 105/65 mmHg IC5sinistra
N : 70 X / minute P : IC5 is felt at IC4sinistra

RR: 22X / minute P : deaf

S: 35, 9 'C A : Bj I and BJ II are pure

3. Head : meschocepal, clean no lesions 5. lung I : symmetrical chest espansi

Neck : no enlargement of the thyroid gland and SPV P : Focal right left hemisphere
eye : conjunctiva not anemic, non-icteric sclera, isocorous P : Sonor
pupil A : vescular
Nose : no polyps, goodsense of smell 6. Abdomen I : Stomach is jaitan
mouth : moist lip mucosa scar covered with obsite
Ear : no cerumen, good hearing P : No tenderness
P : timpani
A : intestinal noise 10x / minute
5. Drugs and genetalia

– Cleanliness: Good

– vagina (Integrity)

– Not odema, lochea rubra, 1 day dressing 2 pads not full of distinctive odor, red.

6. Breast : Symmetrical

Milk : much breast Ability to breastfeed, good

Continued abdomen

• Putting protruding Expulsion ofinvolution Uterus body movement : Uterine contraction both

• Bladder : painless, normal

• Digestive function : patient has never had a bowelafter post SC

• Conditions of wound : dry wound, suture still visible , no edema, no pus

• Calor : no sign of increased temperature in the wound area of

• Dollor : no pain when moving

• Tumor : no swelling

• Rubor : no sign of redness

• Leisa function : disturbing during

7. limb

Extremity Upper limb : not edema, not attachedinfusio

Lower extremity : not edema, not varicose veins

D. GORDON FUNCTIONAL PATTERN
a. Health management
Patients always check the health of the pregnancy once a d. Rest and sleep
month at BPM and ultrasound 2x at the doctor
Before hours at night, 1-2 hours during lunch
b. Elimination
After hours at night and 1 hour during the day
CHAPTER: not during hospital
e. Mobilization and training : -
BAK: 5-6 times / day, yellow is cloudy when BAK is notpain
f. perception and cognition in
c. Nutrition and LiquidNutrition
• thepatients say not know the foods that may
intake, drinkglasses / day of water be consumed after cesarean section and
A : TB: 141 cm patient looked confused and could not answer
when asked a question about nutrition of post-
BB: 50 kg (before 42th) SC mothers
B :- • patients said they did not know the food that
C : Mucosa bib ir moist could be consumed after cesarean section
D : Diit TKTP, the client spends the portion of food • patients said that eating that smelled of meat
provided: 8-9: 6-7 would slow wound healing
g. Sexual and reproductive patterns
Patients said they wanted to be stable because they did not want to have more children
h. relationships and the role of the
patient was a wife with 2 children
i. self-concept
patients accept that the birth of the second child must be SC because the patient knows that
the pelvis is narrow
j. coping mechanism and stress the
patient said that he was not afraid anymore because the first child was also
k. spiritual and imagined the
patient always prayed to recover quickly
E. THERAPY

No Name of drug dosage How to administer

1 Donperidon 3x2 tab Antiematic indications

via oral

2 Vit b, vit a, vit c 2x1 tab Tablet via oral

3 Ceftriazone 2x10 ml Antibiotic indication
via IV
4 Mefenamic acid 3x500 mg Analgesic indication
F. DATA ANALYSIS
NO DATA ETIOLOGY PROBLEMS
1 DS: Invasive procedure Risk ofinfection

− Patients say wrapping of the scars on the former surgery is

uncomfortable because it has not been replaced for 3 days
DO: General condition: good

− Awareness: comp osmentis

− Temperature: 36 oC
− TD: 105/65 mmHg
− Pulse: 70 x / minute
− RR: 22 x / minute
− Leukocytes: 19.25 10 ^ 3 / UL

2 DS: the Less information Deficiensi knowledge

− patient says they do not know the food that can be consumed
after cesarean surgery
− patients say that eating meat that smells will slow wound
healing
DO:

− patients seemed confused and could not answer when asked a

question regarding maternal nutrition post SC
G. Nursing Diagnosis

DX nO Nursing Diagnosis initials

1 Risk of infectionassociated with invasive procedures characterized by leukocytes 19.25 10 ^ 3 /

UL and dressing has not been replaced for 3 days

2 The definition of knowledge related to lack of information is indicated by the patient saying they
do not know the food may be consumed after surgery
 H. NURSING PLAN
Intervention
6540
– Teaching: prescribing diet
infection control
1. Hand washing before and after patient care activities – Assess patient and family regarding cultural views and
other factors that influence the patient's willingness to
Infection protection follow the recommended diet.
1) Monitor for signs and systemic and local symptoms – Teach patients the names of foods that are in
2) Monitor absolute count of granulocytes, WBC, and differential
accordance with the recommended diet.diet
results, Normal (3.98 10.04 10'3 / UL) – Explain to patients about the purpose of adhering to the
3) Keep antibiotic use wisely recommendedrelated to general health.
– 5510
Wound
– Health education.
1) care Give incisional treatment to the required wound
(attachment)
Design and implement strategies to measure outcomes. clients
periodically during and after the end of theprogram
SEKIAN TERIMAKASIH