LINA DEWI UDAYANI

P07124217054
I. SUBJECTIVE DATA
A. Biodata
Mother’s Husband’s
 Name: Mrs. "K" Name: Mr. "Y"
 Age: 26 years Age: 29 years
 Tribe / Nation: Bali, Indonesia Tribe / Nation: Bali, Indonesia
 Religion: Hindu Religion: Hindu
 Education: SMA Education: SMA
 Job : Private Job: Private
 Home Address: Jalan Tukad Batanghari I No. 6C
 Mobile Number: 085935897xxx
B. Current Complaints
The mother gave birth to her baby on September 16, 2020 at
07.00 WITA by SC and felt tired, lack of sleep, abdominal pain
when doing activities, and loss of appetite.
C. Previous Pregnancy and Childbirth History.
Born on September 16, 2020, male gender, birth weight 3200 gr,
gestational age at term, delivery was assisted by a SpOG doctor
in SC, and the baby's condition is currently healthy
D. Current Labor History
In the history of labor, it is now the first delivery, the place of
delivery is at Sanglah Hospital. There were no complications in
stage I, stage II, stage III and stage IV.
E. Marriage History
Mother said this was the first and legal marriage with 1 year of
marriage.
F. History of Use of Contraception
Mother said that she had never used contraception before
because this was her first child.
G. Biological Needs
a. Breathe
Mother said there was no difficulty in breathing and
exhaling.
b. Dietary habit
The mother eats 1 plate with a medium portion consisting
of rice (1 spoon), vegetables (1 spoon), fish or chicken
(several pieces), tofu or tempeh (several pieces) and for
dietary restrictions, the mother says none.
c. Drinking Pattern
The mother drinks 8-10 glasses of water per day
interspersed with drinking 1 glass of milk every day.
d. Elimination Pattern
The mother urinated 4 times a day with a clear yellow color,
the mother said that she had no complaints during BAK.
The mother defecated 1 time a day with a soft consistency
and brownish yellow color, and had no complaints.
e. Rest and sleep
Mother naps for 1 hour, and sleep 6-8 hours per day with
poor quality because it provides breast milk to her baby.
f. Current activity
Mother's activity is currently light, namely the mother is
still resting and breastfeeding her baby and caring for her
baby
g. Mobilization
Mother has not been able to move normally.
h. Personal hygiene
The mother takes a shower and brushes her teeth twice a
day, the mother ishes her hair twice a week. Mothers used
to wash their hands and clean the genitals from front to
back, and change clothes twice a day.
H. Pain
Mother said she felt pain in the stitches of the SC wound.
I. Psychological needs
Mother feels happy and happy with the birth of her first
child, but she still needs help, for now she is experiencing
the psychological adaptation phase of Taking In.
J. Social
Mother said the relationship with her husband was good
and the relationship with her in-laws and other family
members was also good.
K. Plan for Breastfeeding
The mother said that she would provide exclusive
breastfeeding for six months, then continued until the age
of two.
L. Parenting Plans
The mother said she would look after the child
herself with help from her husband.
M. Plans for using contraceptives
Mothers have not planned to use contraceptives,
because they still want to have children.
N. Mother's Knowledge
When taking data, the mother said that she already
knew the danger signs of childbirth, how to check for
contractions, how to do uterine fundus massages,
correct breastfeeding techniques, exclusive
breastfeeding, and postpartum exercise, Kegel
exercises.
II. OBJECTIVE DATA
A. General examination
The general condition of the mother is sufficient with
composmentis awareness. Maternal vital sign was obtained,
maternal temperature was 36.5 °C, pulse 79x / minute , blood
pressure 100/70 mmHg, respiration 20x / minute.
B. Physical examination
1. Face
Mother's face looks pale and there is no edema.
2. Eye
The eyes appear sunken, the conjunctiva is pale and the sclera is
white.
3. Mouth
Looks dry, no dental caries
4. Neck
In the neck there is no enlarged lymph nodes and thyroid
glands and there is no enlargement of the jugular veins.
 5. Breast
 Clean breasts with a symmetrical shape, prominent nipples with
enough milk for the baby, and no swelling and blisters.
6. Chest
 Symmetrical shape of the chest and no retraction.
7. Stomach
 The stomach looks bigger than normal. There are stitch marks that
are not finished / have leaks, there is loose tenderness, the abdominal
wall is tense and stiff like a board. Mid symphysis TFU, uterine
contractions good (loud), bowel sounds are not heard.
8. Lower Extremity
 In the lower limb there was no edema and varicose veins and
symmetrical limbs.
C. Special inspection
 The results showed that genetalia had no tenderness, no swelling of
the skene glands and Bartolini glands, there was no perineal rupture,
discharge of sanguilenta lochea, and normal anal conditions had no
hemorrhoids.
III. ANALYSIS
Diagnosis:
Mrs. "K" 26 years old P1001 PSptB + 5 days post SC with
peritonitis

IV. MANAGEMENT
Date / time of study: Monday, 21 September 2020 / 09.40 WITA
1. Inform the mother and family of the results of the examination that the
mother must be referred so that further examination can be carried out
so that the mother gets special treatment & monitoring from the
medical team and the Sp.OG doctor in administering antibiotic therapy
for the mother. Mother and family consent to informed consent
2. Inform the mother and family that an intravenous line will be
performed as first aid to stabilize the mother's condition. Mother and
family agree
3. Providing mental support to mothers by motivating them to remain
calm and not feel anxious as a form of psychological support to
mothers. Mother feels calmer
4. Make referrals with BAKSOKUDA ​so that patients get proper help at
better health care facilities. The referral is ready and the mother has
been escorted to the referral place.
THANKYOU