CHAPTER 1

PRELIMINARY

1.1 Background
Every woman wants her labor went smoothly and give birth to a baby
perfectly. There are two ways of labor. There are normal labor (through
vaginal) and caesarean sectio. Caesarean sectio is surgery to remove the baby
through incision in the abdominal wall and uterine wall with the condition of
the uterine intact and fetal weight above 500 gram (Wiknjosastro,2007).
Measures sectio caesarean is a best choice for cases to save the mother
and the fetus there are some indication for caesarean sectio. There are fetal
distress, high blood pressure, cephalo pelvic disproportion, labor doesnt
progress, placenta previa, cord prolapsed, fetal percentage mal/location
latitude, PROM (Premature Rupture of Membrane. (Norwitz E & Schorg
J,2007).
The caesarean sectio rate still high the labor with caesarean section is
35,7% to 55,3% with 19,5 to 27,3% is caesarean section with complication
PROM (Premature Rupture of Membrane (Kasdu,2011).
The labor with caesarean section in Indonesian increase. In the last 20
years, from 5% to 20% (Danfort,2000). In East Java, the incident of caesarean
sectio in Dr. Soetomo hospital in 2006 was 1.393 cases (22,4%) of the total
labor (Research Journal,2006)

1.2 Formulating Of The Problem

1. How the concept of caesarean sectio?
2. How the concept PROM (Premature Rupture of Membrane?
3. How the concept of nursing care plan for client with sectio caesarean
labor with indication post PROM (Premature Rupture of Membrane?
4. How the assessment for client with sectio caesarean labor with
indication post PROM (Premature Rupture of Membrane?
5. How the nursing diagnosis for client with sectio caesarean labor with
indication post PROM (Premature Rupture of Membrane?
 6. How the intervention for client with sectio caesarean labor with
indication post PROM (Premature Rupture of Membrane?
7. How the implementation for client with sectio caesarean labor with
indication post PROM (Premature Rupture of Membrane?
8. How the evaluation for client with sectio caesarean labor with
indication post PROM (Premature Rupture of Membrane?

1.3 Purpose
1.3.1 General Purpose
Describe about nursing care plan for client with sectio caesarean
labor with indication post PROM (Premature Rupture of Membrane)
1.3.2 Special Purpose
1. Describe about the concept of caesareann sectio
2. Describe about the concept PROM (Premature Rupture of
Membrane)
3. Describe about the concept of nursing care plan for client client
with sectio caesarean labor with indication post PROM
(Premature Rupture of Membrane )
4. Describe about assessment for client with sectio caesarean labor
with indication post PROM (Premature Rupture of Membrane)
5. Describe about nursing diagnosis for client with sectio caesarean
labor with indication post PROM (Premature Rupture of
Membran)e Describe about intervention for client with sectio
caesarean labor with indication post PROM (Premature Rupture
of Membrane)
6. Describe about implementation for client with sectio caesarean
labor with indication post PROM (Premature Rupture of
Membrane)
7. Describe about evaluation for client with sectio caesarean labor
with indication post PROM (Premature Rupture of Membrane)
1.4 Benefits
To Describe what is the nursing care plan evaluation client with sectio
caesarean labor with indication post PROM (Premature Rupture of
Membrane)
 CHAPTER 2

DISCUSSION

2.1 Caesarea Sectio Concept

2.1.1 Definitions
Caesarea sectio is an artificial labor in which the fetus is delivered
through an incision in the front wall of the abdominal and uterine walls
with the terms on intact uterus and fetal weight above 500 gram
(Sarwono, 2009).
Caesarean section, also known as C-section, is teh use of surgery to
deliver one or more babies. Caesarean section is often performed when a
vaginal delivery would put the baby or mother at risk (Wikipedia).

2.1.2 Types of Caesarea Sectio

1. Caesarea Sectio Transperitonealis Profunda
Caesarea Sectio Transperitonealis Profunda with an incision
in the lower uterine segment. Incision in the bottom of the uterus,
can with transverse or longitudinal techniques.
2. Caesarea Sectio Classic or Corporal
In this Caesarea sectio will made to the uterine corpus, this
surgery is rather easy to dom only held if there are no obstacles to
doing Caesarea sectio transperitonealis deep. Lengthwise incision
in the upper segment of the uterus.
3. Caesarea Sectio Peritoneal
Caesarea sectio peritoneal formerly done to reduce the danger
of porporal injection, but with high progress in medical therapy
toward injection, make a rarely to do surgery. Peritoneal cavity is
not opened but conducted in patients with severe uterine
infection.
4. Caesarea Sectio Histerectomi
Do the indications :
a. Atonic uterine
 b. Placenta accrete
c. Myoma uteri
d. Severe uterine infection

2.1.3 Etiology
Indication mother do Caesarea Sectio are uterine rupture iminem,
ante partum haemorrhage, and premature rupture of membranes. While
the fetus is an indication of fetal distress and a large fetus exceed 4000
grams. From some factors caused Caesarea Sectio, can describe to
several causes of Caesarea Sectio. There are (Manuaba, 2002);
1. PROM (premature rupture of membranes)
2. CPD (cephalo pelvic dispropotion)
3. SPE (several pre eclampsia)
4. Twin baby
5. The factor of obstacle born way
6. Abnormalities location of the fetus
7. Abnormal presentation (breech or transverse positions)

2.1.4 Pathopysiology
Caesarea Sectio is the act of giving birth, above 500 grams with an
incision in the wall of the uterus intact. Etiology action Caesarea Sectio is
CPD (cephalo pelvic dispropotion), SPE (several pre eclampsia), PROM
(premature rupture of membranes), Twin baby, The factor of obstacle
born way, Abnormalities location of the fetus, Abnormal presentation
(breech or transverse positions). While done Caesarea Sectio for mothers
experience pot partum adapotation, in terms of anasthesia, oral fluid
restriction, and the incision. As a result of post partum adaptation of the
physiological an psychological effects. Anesthesia also effect the
digestive tract by reducing intestinal motility. As has been known as the
food enters the stomach, will be a preocess of destruction with the help of
intestinal peristaltic, than absorbed to the metabolism so the body gets
energy. As a result of the decreased motility, the peristaltic also declined.
In addition to the impact on oral fluid restriction that had a risk for lack
of fluid volume. Pain is one of the main due to the incision resulting in
discruption sense of comfort (Saifuddin, Mansjoer, & Prawiroharjo,
2002).
 PATHWAY
CPD (Cephalo Pelvic SPE (Severe Pre PROM (Premature Twin Baby The factor of obstacle Abnormal presentation
Dispropotion) Eclampsia) Rupture of Membrane ) born way

Sectio Caesarea Action

Adaptation after Insicion

childbird

Psychology Wound

Deficient Knowledge Lactation Painful Risk of Infection

of Breastfeeding
method

Flat nipple Disrubtion sense of

comfort

Increase Milk
Production

Ineffective
breastfeeding
 2.2 PROM (Premature Rupture of Membrane)
A. Definition
Premature rupture of membranes is the breakup of the amniotic membrane
before the actual birth start or the breakup of the amniotic membrane before
37 weeks of pregnancy with or without contractions (Mitayani, 2011).
Premature rupture of membranes is defined as a pre-birth membrane
rupture. This can be happen on a pregnancy or long before the time of birth.
Premature rupture of membranes is happen before 37 weeks gestation. The
elongated Premature rupture of membranes is a rupture that occurs more than
12 hours before the time of the birth.

B. Etiology
By the time of gestational age, focal weakness occurs in the fetal
membrane above the internal cervix that triggers a tear in this location / some
pathological oroses (including bleeding and infection) may cause Premature
rupture of membranes. Premature rupture of membranes is also caused by
membrane strength or increased uterine intra pressure or by both factors.
Reduced membrane strength is caused by the presence of infection that can
come from the vagina and cervix. Besides that Premature rupture of
membranes is a matter of obstetric controversy. Other causes are as follows:
a. Cervical Incompetence (Cervix)
Cervical incompetence is a term for congenital abnormalities of the
cervical (cervical) muscles so slightly exposed in the middle of pregnancy
because they are unable to resist the growing fetal pressure
b. Elevation of Intra Uterine Pressure
Intra-uterine pressures that increase or increase in excess can lead
to Premature rupture of membranes
c. Abnormalities of fetal and uterine lying: breech position, location of
latitude
d. Karioamnionitis
 The amniotic membrane infection is caused by the spread of the
vaginal orgasm upwards. The two most important predisposing factors are
rupture of the membranes> 24 hours and prolonged labor
e. Infectious Diseases
A disease caused by a number of microorganisms that cause an
amniotic membrane infection
f. Abnormalities or damage of the membranes

C. Clinical Manifestations
A sign that occurs is the release of amniotic fluid seeping through the
vagina. The scent of amniotic fluid smells fishy and unlike the smell of
ammonia, it may still be seeping or dripping, with a pale trace and striped
blood color. This fluid will not stop or dry because it continues to be
produced until birth. But when you sit or stand, the head of the fetus that is
located below usually block or clog leak for a while. Fever, vaginal spots,
abdominal pain, fetal heart beat rapidly, is a sign of infection that occurs.

D. Patophysiology
Infection and inflammation can cause premature rupture of the membranes
by inducing uterine contractions and / or focal weakness of the amniotic skin.
Many cervicovaginal microorganisms, producing phospholipids C which can
increase local concentrations of arachidonic acid. Platelet activating factors
produced by the fetal lungs and kidneys found in amniotic fluid.
Synergistically also activates the formation of cytokines. The endoxin that
enters the amniotic fluid will also stimulate the cell cell in the second to
produce cytokines and then prostaglandins which lead to the onset of labor.
Human inflammatory cells also describe the flasminogen activator that
converts plasminogen into plasmin, the potential being the cause of ruptured
membranes.

E. Pathway
F. Supporting Investigation
1. laboratory examination
Fluid coming out of the vagina should be examined color
concentration, baud an pH it. Fluid coming out of the vagina except for
amniotic fluid may also be urine or vaginal secret, Secret vagina pregnant
women pH: 4.5, with nitrazin paper does not change color, keep yellow.
a. litmus test (nitrozine test), if red litmus paper turns blue indicates the
presence of amniotic water (alkalis). Amniotic fluid 7 -7,5 blood and
vaginal infections can get a positive or false test.
b. microscope (pokis test), by dripping the amniotic water on the object
glass and allowed to dry, microscopic examination showed a psychic
leaf image.
2. Ultrasound examination
In examination is intended to see the amount of amniotic fluid in
the uterine cavity in the case of LTO seen a small amount of amniotic
fluid. But there are often errors in patients with oligohydramnios although
the approach of diagnosis of Premature rupture of membranes quite a lot
and the way but in general Premature rupture of membranes can be
diagnosed in anamnensis and simple examination.

G. Management
a. Keep the pregnancy samapai matur enough, especially lung maturitas
thus reducing the incidence of failure of healthy lung development.
b. Occurs in the uterine inspection, namely karioamnionitis which triggers
sepsis, fetal meningitis and preterm delivery.
c. With an estimated fetus already large enough and labor is expected to
take place within 72 hours can be given corticosteroids so that fetal lung
maturity can be guaranteed.
 d. At 24-32 weeks' gestation which causes a considerable fetal weighing.
Should be considered for induction of labor, with the possibility that the
fetus can not be saved.
e. Facing Premature rupture of membranes required by KIM against mother
and family so there is a sense that sudden action may be done with
consideration to save mother and may have to sacrifice her jan.
f. Termination time at pregnant term can be recommended intervals of 6-24
hours, otherwise spontaneous HIS occurs

H. Complications
Complications in Premature rupture of membranes, among others, may
lead to: intracerine intracerine intracerine infection from ascending to
intrauterine labor, if it occurs at preterm gestation. Maternal complications
include increased incidence of caesarean delivery (due to malpresetation,
talipore prolapse), intramnion infection (15-30%) and post-natal endometritis,
fetal distress and fetal death due to hypoxia (often in breech presentation or
latitude), oligohydramnios , Often dry partus (dry labor) because the water
runs out.

2.3 Nursing Care Concept of Caesarea Sectio

2.3.1 Assessment
I. Subjective Data
1. Biography
Contains the clients identity includes the name, age (generally occur
in clients age less than 20 years old or over 35 years old), address,
education, ethnicity, marital status, religion, obstetrics diagnosis.
2. Health History
a. Main Complaint
The main complaint the often appear on the client with caesarea
sectio is pain due to the incision / surgery.
b. Current Medical History
 Maternal history of the cause (Premature Rupture Membrane,
Cephalo Pelvic Disproportion, Severe Pre eclampsia, twins, birth
canal resistance factor, abnormal location of the fetus), the current
main complaint would caesarea section operation until action is
taken caesarea section, and post partum mothers during childbirth.
c. Past Medical History
History of mother and baby, obstructed labor, hypertention,
eclampsia, placenta previa, a narrow pelvis, solution placenta, and
other factors. Labor history women who previously had done
caesarea sectio.
d. Family Medical History
A history of abortion in the previous birth, their history
degenerative diseases such as diabetes mellitus, hypertension, etc.
e. History of Midwifery
1) History of Menstruation
a) Menarche : The first age client get a menstruation.
b) Menstrual Cycle : Regularly every month or not.
c) Complaints during menstruation : Their pain before / when /
after menstruation.
d) LMP (Last Menstrual First Day)
e) Interpretation of birth : Namely LMP and than included the
formula (+7 -3 +1) or (+7 +9 +0).
2) Marriage
Contains how many times the client is married, married since
when, if necessary, ask the problems in the relationship with
her husband.
3) History of Pregnancy and Childbirth
A history of previous pregnancy and childbirth (in women
who already have children). If the woman has a history of
more than one marriage, ask the history of pregnancy and birth
since the first husband.
f. Baby circumstances
 The state of the baby after birth, preterm, term, post mature, the
babys weight, height, head circumference, chest circumference,
Apgar score, etc.
3. Medical Function Patterns
a. Pattern of Perception and Management Healthy Living
Reviwing on breastfeeding, post-op self care caesarea section,
how to replace the pads.
b. Pattern of Nutritional Metabolic
The existence of a restriction of food or drink on the client up to 6
hours post surgery recovery. Meanwhile, to replace fluids lost
beverages, clients are given intravenous therapy. Their dietary
restrictions are not allowed during the post-partum-related
restrictions on ethnicity, religion, culture, etc.
c. Pattern of Exercise Activity
In the post-op caesarea sectio client must first bed rest or supine
on a bed without a pillow.
d. Pattern of Elimination
Catheterized for 24-40 hours after surgery to accommodate a lot
of urine elimination that comes out and bowel elimination clients
constipation occur because of the ability to decrease intenstinal
peristalsis.
e. Pattern of Rest Sleep
Clients are more difficult to sleep due to post-op wounds.
f. Pattern of Perception Self Concept
There is a change to the self concept of the client on body image
for post-op wound.
g. Pattern of Sensory Cognitive
Clients post op tend to feel pain because on injuries that never
healded and a lack of knowledge about treatment after surgery
both mother and baby.
h. Pattern of Role Relationships
 A change in a clients role during the operating process to the
cilents condition is stable especially for mothers who already
have children earlier.
i. Pattern of Sexual Reproduction
Clients experienced during childbirth. Sexual intercourse at
puerperal generally not done before the situation stabilized and
improved client.
j. Pattern of Coping Tolerance Stress
Usually client seemed agitated against her and her baby.
k. Pattern of Value Religion
Client running a less than optimal worship during childbirth due
should not be long in advance.

II. Objective Data

1. General Situation
On post operative caesarea sectio client, the client will look weak,
decreased consciousness, and require other in running any activity.
2. Vital Signs
- Blood pressure : Due to the case of continuous bleeding.
- Pulse : Increase of Pulse (100 x / min) due to
continuous bleeding.
- Temperature : The temperature increase on the first client.
If after the second day increase, these conditions indicate an
infection.
- Respiratory Rate : No change in the procces of inspiration and
expiratory.
3. Physical Examination (Head to Toe)
a. Head
- Hair : Black, thin, clean, and no dandruff, no
injuries, no lesions.
- Face : Cloasma gravidarum, symmetry, edema.
 - Eyes : Sclera ikhterus or not, conjunctival pallor
or pink.
- Nose : The presence or absence of polyps,
sinusitis, secretions, as well as the symmetry of the nose.
- Mouth and Teeth : Oral hygiene, presence of dental caries,
oral hygiene and stomatitis.
- Early : symmetry on the cars cleanliness, which
serves good hearing or disturbed.
b. Neck
Enlargement of the jugular vein, thyroid glands, and lymph
nodes.
c. Chest and Breasts
- Inspection : the presence of breast enlargement,
hyperpigmentation of the areola, the cleanliness of the nipple,
nipple protruding or entered into, sores or blisters on the
nipple.
- Palpation : there is time, spending colostrum, lumps, swelling
and hardening of the breast
- Auscultation : the sound of the heart and lung. The presence
of additional breath sound or not.

d. Abdomen
- Inspection : the presence of enlarged abdomen, strie, linea
nigra, surgical scar.
- Palpation : there is diastasis rectal, uterine contractions,
fundus uterine, bladder emptying.
- Auscultation : the presence of bowel sounds.
e. Genetalian
Perineal edema, signs REDAA, vagina hygiene, spending lochea
(color, type, small, amount)
f. Anus
The presence of hemorrhoids, bleeding or not.
 g. Extremity
Thrombophlebitis, edema, varicose veins, patellar reflexes, IV
line.
2.3.2 Nursing Diagnosis
1. Impaired sense of comfort pain associated with the incision the abdomen.
2. Ineffective breastfeeding pattern related to lack of knowledge of mothers
about breastfeeding is right, not smooth milk production, and the nippls
are flat.
3. Risk of infection associated with tissue trauma and demage to the skin
due to surgery.
4. Deficient Knowledge breastfeeding related to information deficient
breastfeeding method.
2.3.3 Nursing Intervention
1. Impaired sense of comfort pain associated with the incision in the
abdomen
Purpose :
after the act of nursing for 1 x 24 hours, the expected pain diminished or
disappeared.
Outcomes criteria :
- client verbalize the pain diminished or disappeared
- client are more quiet and not disturb their activity
Intervention :
a. Determine the clients pain scale
R : determine the level of pine experienced clien
b. Observation vital signs
R : pain resulting in increased blood pressure and pulse
c. Note the uterine tenderness and pain characteristic
R : PP for 12 hour, uterine contractions continue to rise and louder and
stronger
d. Change the position of the client, reduce noxious stimuli, and give a
touch
R : provide comfort to the client
 e. Make a distraction techniques and relaxation
R : reducing pain
f. Teach early ambulation, avoid food and liquids containing gas
R : can reduced the formation og gas and increase intestinal peristaltic
g. Collaboration with medical team I providing analgesic
R : peed up the healing process

2. Ineffective breastfeeding pattern related to lack of knowledge of mothers

about breastfeeding pattern related to lack of knowledge of mother about
breastfeeding is right, not smooth milk production, and the nipple are flat.
Purpose :
After the act of nursing for 2 x 24 hour, the client is expected to be able to
breastfeed affectively.
Outcomes criteria :
- client can perform independently breast care
- client can breastfeed her child property.
Intervention ;
a. Provide information regarding the physiology of breastfeeding,
breastfeeding virtue, and treatment of breast.
R : provide information on the client
b. Demonstrate breast massage and monitor the abiity of the client
performs regularly
R : launch the production of milk
c. Teach the client hoe spending breastfeeding correctly, how
breastfeeding infants.
R : give milk as efficiently as possible of infant
d. Provide support to the mother to carry exclusive breastfeeding
R : to encourage client to give milk spirit
e. Provide description of the sign and symptom of dams on the breast and
breast infection
R : add knowledge to the mother and prevent heir dam
f. Give confidence to the client for breastfeeding
3. Risk of infection associated with tissue trauma and damage to the kin due
to surgery.
Purpose :
After the act of nursing for 3 x 24 hour, I expected to preent infection.
Outcomes criteria :
- There ate no sign of infection
- Wound of lice look good
- The client is not a fever and clear urine production
Intervention :
a. Teach technique of washing hand properly, change dirty pads
R : helps to prevent or limit the spread of infection
b. Review the prenatal hemoglobin and hematocrit. Note the condition the
resulted in clients infection after childbirth
R : anemia, diabetes, and a long labor before a cesarean birth may
increase he infection and show healing
c. Inspection of the abdominal bandage, there I exudate or seepage at the
incision
R : a sterile bandage to cover the wound first 24 hour of after operating
infection. The existence of seepage indicating a hematoma in the
wound
d. Inspection of the incision healing process, watch for sign of redness,
edema, pain, exudate or interference unification.
R : if there are sign that indicate a wound infection caused by
treptococcus.
e. Collaboration with medical team in the delivery of oral anti
inflammation as well as a diet high in protein, and vitamin C
R : prevent dehydration an infection.
f. Observation vital sign
R : temperature increase of more than 38 degrees Celsius within 24
hour after delivery indicated infection.
4. Deficient Knowledge breastfeeding related to information deficient
breastfeeding method.
 Purpose :
After the act of 1x24-hour nursing client knowledge about methods of
breastfeeding increased
Outcomes criteria :
- Mom can demonstrate good breastfeeding
Intervention :
a. Wash hands before and after breastfeeding
R : To prevent infection
b. Provide education on how to breastfeed good
R : Can know the method of feeding properly
c. Collaboration with family to monitor breastfeeding according to the
method taught
R : So that families are able to support breastfeeding effectively
2.3.4 Nursing Implementation
This stage is a real nursing actions the client as a manifestation of all the
action that have been planned at the planning stage.
2.3.5 Nursing Evaluation
Comparison of systemic action plan of the clients problem with the
objectives set done in a way that involves continuous clients and other help
care team.
 CHAPTER 3
NURSING INSTITUTION IN CLOSE POST POSTUM WITH INFECTION
OF EARLY KETUBAN

I. SUBJECTIVE DATA
1. BIODATA
a. Name: Ms. E
b. Age: 38 years old
c. Husband's name: Mr. P
d. Age: 40 years
e. Tribe / nation: Java / Indonesia
f. Marital status: married
g. Religion: Islam
h. Education: Finished High School
i. Address: Surabaya
j. Diagnose: P1001 Post SC secondary primitua + KPP
2. HEALTH HISTORY
a. Main complaint
Clients said she feels pain on post Sectio Caesaria wounds
b. Health history now
On Friday morning, 12 May 2017 at 00.30 a.m client feels
there was a liquid coming out of her vagina while she slept.
She said the water was coming out of her vagina more and so
much more, then she was brought by his family to Suwandi
Hospital at 01.30 a.m but there was no room anymore, and
then the client went to Soetomo Hospital at 03.15 a.m through
IRD and client was handled by a doctor, and the doctor
explained to the client that the liquid which is coming out of
her vagina is amniotic fluid, and Sectio Caesaria Surgery have
to do as soon as possible in order to save the baby.
Client waits for the surgery, until 5.00 p.m she just entered the
operation room, and at 5.30 p.m the baby was born, the gender
was male. After that, the client was moved to ROI at 8.00 p.m.
 On Saturday, 13 May 2017 then both of the client and the baby
were moved to Merpati Room to get further treatment.
c. Past medical history
Client said she had never been hospitalized and never had a
surgery before, and also said that she had no history of
hypertension or a dislocating disease
d. Family health history
Client said that none of her family who has a history of
infectious or declining diseases (such as hypertension, hepatitis
or others) that affecting her pregnancy.
e. Psychosocial history
Client said that she felt anxious when the doctor told her that
the liquid is based on the ruptured membrane and the Sectio
Caesaria surgery has done. But, after the surgery and the state
of the baby is okay the client feel a little bit calm.
f. Family support
Client said that her family really support her during the
pregnancy and her family are always on her side until the time
of the birth.
g. History of midwifery
Menarche: client said her first menstruation is when she was at
the 2nd grade of Junior High School
Menstrual Cycles: The client sayid the period is regular every
month
First Menstrual Haid (HPHT): the client said the first
menstrual period was at last month before she pregnant on 15th
September 2016
Interpretation of labor:
15 08 2016
+7 -3 +1
22 05 2017
 Marriage history: the client said she has married in march 2016
and that was her first marriage
History of pregnancy and childbirth: the client said this is her
first pregnancy.
3. Patterns of Health Functions
a. Pattern of health care perception
SMRS: client said she has shower 2 times a day. She maintains
her personal hygiene, she didnt consume alcohol and also
didnt smoke
MRS: client said that she wipes her body by herself 2 times a
day, she keeps maintaining her personal hygiene, she did it
independently.
b. Patterns of activity and practice
SMRS: the client tells the daily work is as a housewife the
client only do sports 1 times a week the client does not
menglami difficulties in the move
MRS: the client said at the time of hospitalization the client
still has difficulty in the activity due to surgical wound that
cause pain when used excess activity. Despite the limitations
of activity clients still practice so as not to experience physical
weakness
c. Metabolic nutrient patterns
SMRS: clients eat regularly 3 times a day with a sufficient
portion there is no interruption in the diet of the client menu
consists of rice, vegetables and side dishes. Clients also eat
fruit and light cakes as food selingan.klien say drink 2 liters
per day
MRS: clients keep eating regularly 3 times a day eating menu
consisting of rice, side dishes and vegetables client clients
always spend portion feeding from the hospital, clients drink as
much as 500 ml every day for fear of urinating continuously.
 She has lactating her baby but her milk doesnt coming out
fluently. The baby was so fussy while lactating and the
position of the baby looks uncomfort.
d. Pattern of elimination
SMRS: clients say BAB smoothly every day and no
interruption of clients CHAPTER 1 times every morning BAK
1000 cc every day and no interference
MRS: clients say BAB stay smoothly every day and not
interference fixed client CHAPTER 1 times every morning
BAK only 500 cc every day
e. Sleep patterns and rest
SMRS: the client says there is no interruption of sleep patterns,
clients sleep 6-8 hours each day, regular clients break during
the day
MRS: client says sleep is less sound because of having to keep
the baby clients often wake up at night. Clients stay asleep in
the day but only briefly
f. Cognitive and perceptual patterns
SMRS: the client says there is no interference on the five
senses the client's normal client thinking patterns do not use
tools for the client's memory senses are still quite good
MRS: client states no change on the five senses. The client's
thinking process remains good
g. Pattern of tolerance-koping stes
SMRS: The client says that if there is a problem, he tells his
husband and is teradag to his mother.
MRS: the client says soon go home and always ask the doctor
h. Patterns of self-perception of self-concept
SMRS: clients say have a good sense of confidence, clients do
not have negative feelings like helplessness and feel hopeless
 MRS: the client says there is no self-concept disturbance, the
client has a high spirit, the client still has a strong confidence
to get well soon and can take care of his child well.
i. Sexual Reproduction Patterns
SMRS: the client says there is never a sexual and reproductive
disorder.
MRS: clients experience limitations in sexual problems
because they are still in the puzzle. The client has 1 son
j. Pattern Relationships and Roles
SMRS: clients say have a good relationship with family and
neighbors. Clients follow following neighborhood assembly
MRS: Client said after hospital admission to other patients,
family and health personnel. During the patient's hospital is
maintained by the mother and her husband
k. Patterns of values and beliefs
SMRS: the client is Islamic and carries out his duty to pray 5
times
MRS: The client says just pray that he cepet healed
II. OBJECTIVE DATA
1. Vital sign
a. Blood pressure: 110/70 mmHg
b. Nadi: 80x / min
c. Temperature: 36.5 C
d. Respiratory: 18x / min
2. Height: 156 cm
3. Weight: 48 kg
4. Physical Examination (Head to Toe)
A. Head
1) Hair : client hair is black, straight, and clean.
2) Advance : client face is not edema, not pale, but the
client's face occasionally grinned because it
holds pain and holds the stomach of surgery.
 3) Eyes :conjunctiva not anemis, white isctic sclera.
4) Nose : no polyps or sinusitis, and a symmetrical
nose.
5) Teeth and mouth : no dental caries, no mouth ulcers.
6) Ears : symmetrical, no lesions, no serumen.
B. Neck
1) The tyroid gland : no swelling of the tyroid gland.
2) Jugular vein : no jugular vein enlargement.
C. Chest
1) Heart : normal heart sound, S1 and S2 single.
2) Lungs : normal lung sounds, no additional
Wheezing or Ronchi sounds.
3) Breast : discharge of milk is not smooth, flat left
nipple shape, dirty breasts, a little hard, and
the position of the bab y when suckling
uncomfortable.
D. Abdomen : scarring of SC surgery, dry wound, TFU 3
fingers below the center, bowel sounds 12 x
/ min, there are stomach pressure sores.
E. Genetalia : clean genetalia, there is a rubra lochea
F. Extremities : no odema and no varicose veins.
5. Supporting investigation
May 15, 2017 Hours: 12:32

Clinical Chemistry Clinical Results

No Parameter Results Unit Reference

value
1 Direct bilirubin 0,42 mg/dl <0,20
2 Total bilirubin 8,76 mg/dl 0,2 1,00

Results of Hematologic Examination

No Parameter Results Unit Reference
 value
1 HGB 17 g/dl L : 13,3 16,6
P : 11,0 14,7
2 RBC 4,67 10^6/L 3,69 5,46
3 HCT 47,0 % L : 41,3 52,1
P : 35,2 46,7
4 MCV 100,6 fL 86,7 102,3
5 MCH 36,4 pg 27,1 32,4
6 MCHC 36,2 g/dl 29,7 33,1
7 RDW-SD 54,0 fL 41,2 53,6
8 RDW-CV 14,6 % 12,2 14,8
9 WBC 10,69 10^3/L 3,37 10
10 PLT 353 10^3/L 150 450
11 PDW 12,4 fL 9,6 15,2
12 MPV 10,2 fL 9,2 12,0
13 P-LCR 26,6 % 19,7 42,4
14 PCT 0,36 % 0,19 0,39
15 IPF % 1,1 6,1
16 RET# 10^6/L 0,034 0,100
17 RET% % 0,80 2,21
18 IRF % 3,2 13,3
19 LFR % 87,1 98,3
20 MFR % 3,1 11,8
21 HFR % 0,1 1,4
22 RET-He % 31,9 37,3

6. Given Therapy
Mefenamat acid 500 mg/ 8 hours
 DATA ANALYSIS

Data Grouping
Cause Nursing Problems

DS : Premature Rupture of Risk of infection

The client said the SC membranes
operation on 13 May 2017

DO : Surgical Incision (SC)

a. There are abdominal
surgery wounds
b. There is tenderness in the Abdominal wound
abdomen
c. Temperature: 36.8 C
d. WBC: 10,9 10 ^ 3 Disconnected network
(Normal value 3 - 10 10 ^3) continuity

Risk of infection
DS : Premature Rupture of Pain
Clients say pain in wound membranes
surgery (SC)
P : Pain is made when
activity is created Surgical Incision (SC)
Q : Pain-throbbing pain
R : Pain in the surgical
wound (on the Abdominal wound
abdomen)
S : Pain scale 5
Q : Pain disappears for 1 Disconnected network
minute continuity

DO :
a. The client's face grinned Acute Pain
with pain
b. TTV:
Blood pressure: 120/80
mmHg
Temperature: 36.8 C
Nadi: 84 x / min
Respiratory: 21 x / min

DS : Post Partum Ineffective Breastfeeding

Mother said breastfeeding is (The first child)
not fluent
DO :
Nipple is flat
a. The left nipple is flat
b. The breasts are dirty and
a little hard
Ineffective
Breastfeeding
DS :Clients say baby fussy Post Partum Deficien of Information
when netek (The first child) on breastfeeding methods

DO :
Position baby when sucking Deficien of
uncomfortable and less Information on
precise breastfeeding methods