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  • Nursing Resume Poli Kandungan

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    mutia a
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    This nursing resume summarizes the care provided to a 33-year-old pregnant patient, Mrs. H, who presented with pain in her left hand. Upon examination, the patient appeared grimacing and had an elevated blood pressure and pulse. The nurse diagnosed the patient with impaired comfort likely related to the pregnancy. The nurse's care plan was to manage the patient's pain through non-pharmacological methods like breathing exercises and activity modification. After treatment, the patient reported reduced pain levels and no longer appeared in discomfort before being discharged.

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    Nursing Resume 01

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    This nursing resume summarizes the care provided to a 33-year-old pregnant patient, Mrs. H, who presented with pain in her left hand. Upon examination, the patient appeared grimacing and had an elevated blood pressure and pulse. The nurse diagnosed the patient with impaired comfort likely related to the pregnancy. The nurse's care plan was to manage the patient's pain through non-pharmacological methods like breathing exercises and activity modification. After treatment, the patient reported reduced pain levels and no longer appeared in discomfort before being discharged.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    8 tayangan2 halaman

    Nursing Resume Poli Kandungan

    Diunggah oleh

    mutia a
    This nursing resume summarizes the care provided to a 33-year-old pregnant patient, Mrs. H, who presented with pain in her left hand. Upon examination, the patient appeared grimacing and had an elevated blood pressure and pulse. The nurse diagnosed the patient with impaired comfort likely related to the pregnancy. The nurse's care plan was to manage the patient's pain through non-pharmacological methods like breathing exercises and activity modification. After treatment, the patient reported reduced pain levels and no longer appeared in discomfort before being discharged.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 2

    NURSING RESUME POLI 01

    Student’s Name : Mutia Adeline

    SRN : 1614401110053

    Ward : Poli Kandungan

    A. PATIENT’S IDENTITY
    Name : Mrs. H
    Age : 33 years old
    Address : Jend. Sudirman rt 014
    Medical Diagnosis : G2 P1 A0
    Entry Date : Monday, July 30th 2018
    Assessment Date : Monday, July 30th 2018
    B. FOCUS DATA
    Subjective Data :
    Patient said want to check her pregnant. Patient complained that there’s pain in her left
    hand since 1 weeks ago
    Objective Data :
    Inspection : Patient's stomach enlarged (5 months pregnant). Patient look
    grimacing.
    Palpation :
    Leopold 1: TFU is 2 fingers down the umbilical.
    Leopold 2: the lateral part of the patient's left abdominal wall is the baby's hands
    and feet, the lateral part of the right abdominal wall of the baby's back
    Leopold 3: the lowest part of the baby can be moved
    Leopold 4: -
    Auscultation : DJJ 144x/mnt
    Percussion :-
    C. EXTRA DATA
    a. Vital Signs
    - BP : 160/100 mmHg
    - P: 100 x/mnt
    b. History of obstetrics
    Menarche: 12 years old
    Long period: 7 days, the period cycle is regular.
    HPHT: January 01th 2018
    HTP: October 20th 2018
    c. Supporting Examination
    USG: not confirm

    D. DATA ANALYSIS
    DATA PROBLEM ETIOLOGY
    S: Impaired comfort
    Patient complained that
    there’s pain in her left
    hand since 1 weeks ago
    O:
    Patient look grimacing.
    - BP : 160/100
    mmHg
    P: 100 x/mnt

    E. NURSING CARE PLAN


    Nursing Diagnose :
    Impaired comfort related to
    Goals:
    After given nursing care, patient is expected to feel more comfortable with the her
    situation.
    Result Criteria:
    NOC: Pain level >> patient does not seem to wince
    Intervention
    NIC: Pain management
    1. Exploring factors that can aggravate the patient's pain
    2. Teach how to use non-pharmacological therapy.
    3. Eliminate precipitation factors that can improve the client's pain experience
    Implementation
    1. Exploring factors patient’s pain. Patient said pain appear when contractions come.
    2. Teaches deep breathing exercises.
    3. Give health education about pregnancy exercise
    Evaluation
    S: Patient said pain is reduced
    O: Patient didn’t looks grimacing
    A: Patient report reduce pain (noc scale 4)
    P: Discharged planning. Plan for re-control

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