ASSESSMENT

Name : Ms. D

Age : 26 th

Sex : Famale

Marital Status : Married

Occupation : Housewife

Date : August 12, 2019

Time : 13.00 Pm

Primary Language : Indonesia

Arrived Via : Ambulance

From : Other

Family G.P : Husband

Weight : 70 kg

Height : 165 cm

BP : 110 / 90 mmHg

Temp : 37,3 °C
Pulse : 110 x/m
Resp : 20 x/m

1. Reason for admission ( Onset, Duration, Pt’s Perception) :

Pain in the wound SC, Dura on 30 minute,

2. Usual health status :

Ms. D have performed operations sito sectio Caesaria on Monday 12th
August 2019. Ms.D post operative SC 13:00 pm. Patients lie, lie on and a
painful experience. The pain felt after 4 hours of operation and the wane.
Ms.D feel pain when moving the scale 6. Pain is felt when Ms.D move, pain
is stabbing skewers for 10 menitan, pain is around the abdomen.

3. Chronology of the illness :

the client said this had never been pregnant and clients first pregnancy and
 childbirth. Ms. D said that since her pregnancy her blood pressure became
high so it was not possible to give birth normally

4. Effect of the illness on the patient’s daily life :

After surgery patient feel pain and imobilized.

5. Previous hospitalization :
Ms. D said this is the first time being treated at a hospital

6. Pevious Surgery :
Ms. D said this was her first time operating

7. Childhood Diseases :
Ms. D said her mother had had hypertension since 15 years ago
 IMPLEMENTATION

Tanggal Tanggal

No Intervention August 12, 2019

Signature N M E Signature N M E

Dx 1: pain r/ t kontuinitas network outages

Assess the intensity, the characteristics, and

1
the degree of pain.

2 Maintain bed rest during the acute period.

Describe the pain suffered by the client and

3
the cause.

4 Teach distraction techniques.

5 Collaboration analgetik.

Dx 2: Impaired physical mobility r/ t postoperative wound sectio caesarea

1 Assess the level of the client's ability to move.

 Assess the influence of activity on the
2 condition of the wound and general body
condition.

Help clients to meet the needs of everyday

3
activities.

Help clients to take action in accordance with

4
the capabilities / conditions of the client.

Evaluation of client capability development

5
activities.

Collaboration dengan doctors in the provision

6
of drug therapy
 EVALUATION

NO DATE EVALUATION

DX1 August 12, 2019 S:

“This pain makes me uncomfortable, like a sharp object
piercing”
“I am afraid to move because of pain”
“I will lie down when the pain is felt “
” I will take a deep breath to reduce pain”

O:
- the patient looks grimaced.
- pain scale 2
- the patient can take a deep breath

A:
pain r/ t kontuinitas network outages

P:

- Collaboration analgetik.

DX2 August 13, 2019 S:

“I do not dare to sit down, all my activities are helped by my
husband “
“I can tilt right and tilt left “
O:
- patients use pempers
- the patient eats with her husband

A:
Impaired physical mobility r/ t postoperative wound
sectio caesarea

- P:
Helping clients to meet the needs of everyday
activities.
- Helping clients to take action in accordance with the
capabilities / conditions of the client
- Clients are able to do activities with the help of
- Evaluate client capability development activities
- Collaborate with doctors in the provision of drug
therapy