Nursing care at Ny.

Painful Discomfort Associated With SC Post Injury

Wijaya Kusuma 9 Hospital Muhammadiyah Cepu

Disusun Oleh :

MIROTUL ROHMAH

P1337420416072

2B

POLTEKKES KEMENKES SEMARANG

PRODI DIII KEPERAWATAN BLORA

2018
 Nursing care at Ny. S

Painful Discomfort Associated With SC Post Injury

Wijaya Kusuma 9 Hospital Muhammadiyah Cepu

1. BIODATA
Name : Ny.S
Age / date of birth : 38 th / 08 June 1979
Occupation : Housewife
Education : Elementary School
Gender : Female
Religion : Islam
Address : Ds. Penting Rt 04 Rw 01 Curse
No Register : 47. 87.16
Medical diagnosis : Post SC Pre Eclampsy Weight

Person in charge
Name : Mr. S
Age : 45 years old
Occupation : Teacher
Address : Ds. Penting Rt 04 Rw 01 Curse
Relationship with the client : Husband

2. The main complaint

Patients say pain in post sc lesions
P: Pain increases as it moves
Q: Pain as burning
R: Lower abdomen
S: Scale 5
Q: Continuously
3. Current medical history
Patients with G1P2A0 post Sc H2 due to PEB with TD: 180/110 mmHg N: 80 x
/ min S: 36.2 C Proposed SC on November 15, 2017 at 07.00 WIB patients in SC
surgery at PKU MUHAMMADIYAH CEPU Hospital. After the patient's surgery
move in wijaya kusuma further.
4. Past medical history
Patients said previously had hypertension
5. Family health condition
The patient said his family also has hypertension
6. Physical examination
General state : Looks limp
Awareness : Full GCS: E4 V5 M6
Vital signs : TD: 180/110 mmHg,
N: 80 x / min,
S: 36.2C,
RR: 19x / min

Head
Head shape : Normal
Hair : Not falling out, oily
Scalp : Clean no dandruff

Eyes:
Visual acuity : Normal, can see clearly
Sclera : Not jaundice
Conjunctiva : Not anemis
Pupil : Normal
Field of view : Normal
use of the tools : Do not use the tools to see

Nose
Polyp sinusitis : No sinusitis polyp
Inflammation secretions : No bleeding and no secretions
Olfactory function : Normal
Ear
Hearing function : Normal

Mouth
Lips : Dry
Teeth : No caries
Gums : No bleeding
Tongue : Normal
Inflammation : There is no inflammation
Speech function : Normal
Tasting function : Normal

Neck
Stiff neck : The patient does not feel stiff neck on the nape of the neck
Difficult to swallow : Patient is not difficult to swallow
Gland enlargement : No enlargement of the gland

Chest
Shape : Symmetrical
Examination of breast : No lumps, no pain
Breath sound : Normal

Heart
Heart rate : 80x / min
Chest pain : No chest pain

Abdomen
There is a post sc scar approximately 15 cm covered bandages

Muskulosskeletal
Muscle strength : Normal
Muscle tone : Normal
Stiff joint : Normal
Reflex : Normal
 Skin : Normal

7. The pattern of daily life

Drinking diet
Before sick : Eat 3x a day consumed one serving
Drink 7-8 glasses per day

During illness : Eat according to hospital diit finished half

drink 4-5 glasses per day

Patterns of rest and sleep

Before getting sick : Patients say sleep soundly 7-8 hours per day
During illness : Patients say difficulty sleeping 4-5 hours per day

Pattern of elimination
Before getting sick : Patient defecation and normal urination
During illness : Patients have not defecated, the patient was able to urinate

Personal hygine patterns

Before sick : 3x daily bath patients, brush your teeth, shampoo 2 times a
day
During illness : 1 bath patient a day in nurse aids