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I. Patient Identity
Name:
Age
Marital status :
Religion:
Tribe:
Education:
Husband's name :
Address:
Job:
Medical diagnosis:
Date of entry Rs:
A. Major Complaints
Stomach pain passes back
B. Main complaint history
Clients say the stomach pain is backward, with an opening of 8 and accompanied by mucus
secretions mixed with blood through the vagina, the client says whenever the pain feels like to
strengthen.
II. DATA HEALTH
A. TB: 154 cm
BB: 57 Kg
Before pregnancy: 46 kg
B. There are no specific health problems in the patient
C. No history of drugs consumed
D. No allergies
E. There is no special diet
F. No use of tools
CHAPTER: 1 x / day
BAK: 3 x / day
III. DATA MATERNITY
A. Pregnancy now: Planned
B. G3 P2 Ao
C. UK: 41 weeks
HPHT: 1-04-2015
THP: 09-11-2015
D. Child data
No Gender Birth mode Birth place BB birth m.kes Age of age
1

3 Pr

Pr

Pr Spontaneous

Spontaneous Hospital
Hospital
Hospital 2400

3600

3300 missing
Nothing
No good

Good

Good
15 yrs

10 yrs

1 day
E. Following antenatal care: clients follow antenatal care
F. Past pregnancy / childbirth problems: the client has had difficulty in giving birth to the second
child
G. Pregnancy problems now
Trisemester 1: Hyperemesis
Trimester II: no
Trisemester III: no
H. Contraceptives used and problems arising: the client has used a pill for 3 years
I. Birth control plan after pregnancy: clients plan to use spiral contraception
J. Previous Baby Food: Exclusive Breast Milk
K. Health education to be obtained during treatment is breast and contraception
L. Expected to help during the birth of this baby are the husband of the client and the midwife
IV. Psychosocial Data
A. Family / month income: Rp. 1,5 million
B. Mother's feeling about pregnancy inj: the mother feels anxious because it is still traumatized
by the birth of her second child.
C. Couples feelings about this pregnancy: the client's husband tells his wife's circumstances to
the midwife and doctor.
V. Physical assessment
A. Face
INFECTION: facial expression tamoak cry no accne, face looks pale, no cyanosis.
Palpation: muscle strength maseter and temporalis well.
B. Eyes: conjunctiva not anemic, sclera not ikretrus
C. Nose
Infection: no mass, left and right symmetric nostrils no secrept and good olfactory function
Palpation: there is no tenderness in the frontal and maxillary sinuses
D. Ear
Inspection: no blockage, no serumen and good hearing function
Palpation: no tenderness
E. Mouth
Inspection:
Lips: symmetrical lips, no lesions and canker sores
Teeth: the number of complete teeth, cavities
Gums: no mouth ulcer
Mucosa: does not look moist
Tongue: can not blotch
Palatum: there is no polatocisis
Tonsil: no visible enlargement
Throat: no pain during swallowing
F. Neck: no visible enlargement of the thyroid gland
G. Breasts: prominent nipple, blackish brown aerola, no mass.
H. Abdomen
Inspection: the stomach looks big and round, looks tense at his time
Palpation: good uterine contractions, palpable hard
Leopoid I: 30 cm
Leopoid II: the position of the cook
Leopoid III: the lower part of the head
Leopoid IV: head has entered the PAP
Percussion: sonor
Auscultation: DJJ: 132 x / m
I. Genetalia: Distribution of hair evenly
Vagina: Looks a complete opening and looks white mucus
J. Anus: Pereneum stretch
VI. Birth history now
I. Kala 1
A. Nausea contraction, date ......... clock ...... .. WITA
B. Current contraction: 3 x 110 (40-45)
C. Start pervogina spending, date ......... .jam ....
D. DJJ: 132 x / m
E. TB: 154 cm
BB: 57 kg BB before pregnancy: 50 kg
F. TD: 100/80 mmHg N: 80x / m P: 20x / m s: 36c
G. Extremities: no udema appears
H. In-check
Hour :
By: Midwife
Hasail opening: complete opening
Fetal: broken date: ......... clock: ......
1. Therapy given
Day Date Type of therapy Route Dosage Indication
Oxytocin
Netusin
Acid mefanat IV
Oral
Oral 3 cc
3x1
3 x 1 Contraction
Analgesic
Analgesic
DATA CLASSIFICATION
Subjective Data Objective Data
1. The client says abdominal pain
2. The client says the pain scale is 9 (10-10) heavy
3. Clients say the pain is felt 8 hours ago
4. Pain increases during fetal contractions
5. Client says Pain decreases when the client breathes deeply
6. Client says still traumatized with child second child 1. G3 P2 Ao
2. Facial expression crying
3. The face looks pale
4. Contraction 3x / minute
5. Abdomen looks tense when His
6. Clients look moody
7. Clients look lethargic
8. DJJ: 132 x / m
9. TTV:
TD: 100/70 mmHg
P: 20 x / m
N: 80 x / m
S: 36 c
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Diagnosis of Keperawatn
1. Acute pain b / d Uterine contractions
2. Anxiety b / d less knowledge about childbirth
Nursing Plan
No Nursing Diagnosis Rational Intervention Objectives
1