NURSING CARE REPORT OF Mrs.

A WITH MEDICAL DIAGNOSIS

ABORTUS INCOMPLIT IN BANJARMASIN ULIN GENERAL HOSPITAL

by :
BAHRIYANOOR
010011D3KI

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE

INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM
ACADEMIC YEAR 2013

NURSING CARE REPORT

Student Name
Srn
Day / Date
Ward

: Bahriyanoor
: 010011d3ki
: Sunday / 14-1-2013
: VK Pregnancy

A. Client Identity
Wife
Name
Age
Nationality
Religion
Occupation
Education
Address
Marital status

Husband
Name
Age
Occupation
Education

: Mrs. A
: 18 years old
: Indonesia
: Islam
: Housewife
: Junior high school
: Jl. Gambut Banjarmasin
: Married
: Mr. S
: 20 years old
: Private
: Junior high school

B. Nursing History
a. Main complaint
Client said that she feel pain on the abdomen and anxiety.
b. Mother perception to pregnancy
Client said that feel anxiety because his pregnancy problem.
c. Its pregnancy can make change behavior his pregnancy problem
No change with live day.
d. What the hope of mother during pregnancy
She want have baby.
e. Mother stay with
Husband.
f. Who important person for mother
Husband and parents
g. Attitude family member what mother pregnancy
All family care with her.
h. Mental already for to be mother
Yes.
C. Obstetric History
a. History of menstruation :
Menarce
: 13 years old

Siklus
: 28 day
Dismenoria
: nothing
More
: 7 day
HPHT
: 10-8-2012
Age pregnancy
: 12 weeks
Tafsiran pregnancy : 17-05-2013

D. Pregnancy History, Nifas Age :

Child number

No

Years

2012

Pregnant
Pregnancy
period
18 W

Delivery

Problem

Types

Helper

Abortus

Curreta
ge

Doctor

Obstetric Complication
difficul
t
-

Lacera
tion
-

Infection

Bleeding

E. Now Pregnancy
F. History Of Family Plan
No use contraception
G. Health History
The disease there was no that mother had
The family there was no that disease
H. Specially Needs
A. Nutrition
a. Frequency eat
: 3 times / day
b. Kind food
: vegetable and vegetarian
c. Allergy
: nothing
B. Elimination
Urinated
a. Frequency
b. Color
c. Complaint between with urinated
Defecated
a. Frequency
: 1 times / day
b. Color
: yellow
c. Smell
: yes
d. Consistention : e. Complaint
: nothing

: 5-6 times / day

: good
: nothing

C. Personal Hygiene
Client take a bath 3 times / day, and make soap body, teeth brush and wash hair.
D. Rest and sleep

Client sleep was 8 hours / day and before sleep client always watching television.
E. Activity and training
Activity in job
: Help parent
Job time
: morning
Sport
: jogging
F. Daily health influence
Client not smoking and drunker
I. Physical Assessment
a. General assessment
General assessment
Blood pressure
Respiration
Body weight
Consciousness
Pulse
Temperature
Body tall

: Fine
: 130/90 mmHg
: 24x/m
: 40kg
: CM
: 85x/m
: 36,3oc
: 145cm

b. Sight
Eyes position
Eyes ball
Eyes movement
Eyes ball movement
Conjunctiva
Cornea

: symmetric
: normal
: normal
: normal
: normal
: normal

c. Respiratory
Airways
Breathing
Sound breath
Use muscle breath

: clean
: good
: vesikuler
: no

d. Heart circulation
Pulse heart
Sound
Chest pain

: 87x/m
: regular
: no

e. Digestive
Mouth condition : clean

Teeths
Abdominal

: good
: pain

G. Data Analysis
No
1
-

Data
DS
Client said that she felt abdominal

pain
Client said that she out blood in
vaginam

DO
Client looked hld the pain
P : Movement Q : Stabling
R : Abdominal Area S : 1 ( mild )
T : 3 second
Looked blood

H. Nursing Diagnosis
1. Bleeding Related To Abortus Incomplit
I. Intervention
Dx
:1

Problem
Bleeding

Etiology
Abortus incomplit

Goal
Result

No
1
2
3
4
5
6

: in 1x6 hours bleeding can be tolerated with

: - abdominal pain is reduce
- client looked relax
- nothing blood

Intervention
Assess the client level of pain
Encourage relaxation and distraction
Give area comfort and private
Give inform consent for client
Observation vital sign
Collaboration with team medic team

No
1
2
3
4
5
6

Rational
To next intervention
To comfort
For the privacy client
For
knowledge
about

next

intervention
To know conditional client
For out think asing fetus

for do curettage abortus incomplit

J. Implementation And Evaluation
No
1

Day/Date
Monday
14-1-2013

No dx
Implementation
Evaluation
I
1) Assessing level of pain - S : the client said that she felt
client
abdominal pain and felt out
E/ 2 ( medium )
blood in vaginam.
2) Observation vtal sign
E/ all normally
- O : the client looked comfort,
3) Encourage
technique
vital sign result in all
relaxation distraction
E/ client felt comfort
normally
4) Client preparation
giving inform consent - A : Problem have been solved
about next intervention.
- P : Stop intervention
suggest fasting
E/ client cooperative
5) Collaboration with team
medic

cuuretage

abortus

incomplit.
E/ client do curettage.