NURSING PROCESS ON MRS.

T WITH MEDICAL
DIAGNOSIS POST SC WITH DKP INDICATION
IN SRIKANDI WARD NYI AGENG SERANG
HOSPITAL

ARI NINGSIH (P07120217011)

ERVIETA ADISTYA H. (P07120217018)
FAISAL ADITIA M. (P07120217019)
FATHINA DJUANISA R. (P07120217021)
JULIA TRI WINAHYU (P07120217023)
ASSESSMENT
Patient Identity
1. Name : Mrs. "T"
2. Age : 33 years
3. Place / DOB : Kulonprogo, December 2, 1988
4. Religion : Islam
5. Ethnic groups : Javanese / Indonesian
6. Education : S1
7. Occupation : PNS
8. Address : Karanganyar, Giripurwo, Girimulyo
9. Entry date : October 6, 2019
10. Assessment date : 7 October 2019
11. Medical Record Number : 0258xx
12. Medical diagnosis : Post SC with DKP indication
Identity of Person in Charge
1. Name : Mr. "A"
2. Age : 34 years
3. Place / date of birth : June 13, 1985
4. Religion : Islam
5. Ethnic groups : Javanese / Indonesian
6. Education : S1
7. Occupation : PNS
8. Relationship with clients : Husband
9. Address : Karanganyar, Giripurwo, Girimulyo
GENERAL HEALTH HISTORY
Current Health History
• Main Complaints
The client said that the gestational age was 38 + 8 but there was no sign of labor. Referral
patients from Puskesmas Girimulyo 1 with information from G2P0A1 indicating DKP for
further treatment.
• Complaints During Post SC Review
The client said breast milk has not come out and the baby has not sucked strongly. The
client said that he did not yet know how to treat breast and breastfeeding techniques
correctly. Client's breasts do not appear swollen, the position of breastfeeding the baby
looks wrong and the baby is reluctant to suckle. The client says that the client issues a
brownish red lochea,. The client said pain in his stomach or a former SC operation with a
scale of 3 out of 10. The client seemed to wince when moving his body. The client appears
to protect the area of ​pain. The client said that the pain in his lower abdomen was severe and
did not spread. The client says pain arises when the client moves his body. The client says
the bandage hasn't been replaced
 • Previous medical history
The client said he had been hospitalized in 2018 because he had a history of
abortion once with a gestational age of 11 weeks 4 days.
• Family health history
The client says that the client's family has no history of hereditary diseases such
as asthma, DM, hypertension, etc.
GENERAL CONDITIONS
1. Awareness : Composmentist
2. Nutritional status:
• Height : 155 cm
• Body weight : 60 kg
• BMI : 24.97 kg / m²
3. Vital Signs:
• Blood pressure : 120/70 mmHg
• Temperature : 36.6 ˚C
• Pulse : 82x / minute
• Respiration : 21 x / minute
OBSTETRIC HISTORY

Menstruation Status
1. Menarche Age : 15 years
2. Long period : 5 days
3. Menstrual cycle : 28 days
4. Color : blood red
5. Smell : Blood
Marriage History
6. Status : Married
7. Age of first marriage : 27 years
8. Frequency of getting married : 1 time
9. Length of marriage to current husband : 6 years
Pregnancy History Now
10. HPHT : January 3, 2019
11. Parturition Estimation : October 10, 2019
12. Age of Pregnancy : 38+ 8 mg
13. BB before pregnancy : 60 kg
14. Addition of BW during pregnancy : 9kg
15. ANC History : She check up every month to the obstetrician, she received tetanus immunization in
trimester 1 and consumed Fe tablets regularly in all
• Birth History
1. Type of delivery : Caesarean Sectio
2. Assisted by : Doctors and medical teams
3. Sex of the baby : Male
4. Length and weight : 45 cm / 2885 gr
5. APGAR score : 8/9
6. Labor complications : DKP
• KB history
1. KB History : None
2. Upcoming KB plans : Yes
3. Method : IUD