nursing care of patients
TRANSCRIPT
NURSING CARE OF PATIENTS
antepartum haemorrhage
Antepartum bleeding is bleeding from the genital tract that occurs between the 28th week of
pregnancy and early parturition.
At one pregnancy bleeding from the genital tract is more frequent and serious if it occurs at the site
of the placenta than from other sources. Nevertheless, the placenta becomes definitive organ
considerably earlier than 28 weeks of pregnancy and bleeding can occur earlier. Although bleeding
after this time are more common. Although vaginal bleeding after 29 weeks should be considered
potentially serious.bleeding at the time that can be an early indication of the two main causes of
bleeding anterpatum namely;
• Placenta previa
• placenta Soluto
3.1. Placenta previa
Definition 3.1.1
In normal keaadaan. Placental implantation or located at the fundus of the uterus. Placenta previa is
a placenta that is abnormally located in the lower segment of the uterus, which may cover part or all
of the opening of the birth canal.
3.1.2. Etiology
What is the cause of the placental area implatasi lower uterine segment can not be
explained. However, there are several factors that are associated with increased frequency of
placenta previa occurs, namely:
• Parista
The more parista mother, the greater the possibility of having placenta praevia
• Maternal age at the time of pregnancy. When a pregnant mother's age at the time of 35 years or
more, the greater the likelihood of pregnancy placenta previa.
• Age of dam parity
- At the age of above 35 years old primigravida more frequently than under the age of 25 years.
- At high parity is more frequent than in the low parity
- In Indonesia placenta previa often found in small parity age caused many Indonesian women marry
at a young age where the endometrial immature.
• The presence of tumors: uterine myoma, endometrial polyps.
• Sometimes on malnutrition
Classification
Based on terabaya placental tissue through the opening of the birth canal at any given time,
placenta previa is divided into four classifications, namely:
1) Placenta previa totalis when all of the opening is covered by the placenta jarngan
2) Placenta previa parsialis when some opening ternutup by placental tissue
3) Placenta previa Marginal when the edge of the placenta is on the edge of the opening terpat
4) when the placenta lies low under the segment beyond the edge of the placenta but did not reach
the edges internum ostium.
5)
3.1.3. Clinical manifestations
• Bleeding can occur more or less. Bleeding that occurs the first time, usually not much and not be
fatal.Subsequent bleeding is almost always much more than before. Bleeding often occurs first in the
third quarter.
• Patients who present with bleeding due to placenta previa do not complain of pain.
• In the uterus was not palpable hard and tense.
• The bottom of the fetus is usually not yet entered the pelvic and not infrequent fetal position
( latitude location or layout sunsang)
• The fetus may be alive or dead, depending on the amount of bleeding. The majority of cases, the
fetus is still alive.
The main symptoms
• Bleeding that occurs colored fresh, without reason and without pain is the primary symptom
Complications
• Anemia due to bleeding
• Shock
• Fetal death and premature birth in a state of severe asphyxia.
3.1.4. Pathophysiology
anterpatum bleeding caused by placenta previa generally occurs in the third trimester of
pregnancy.Because at that time the lower uterine segment experienced more changes in relation to
getting her pregnancy.
Possible anterpatum bleeding due to placenta previa since 20 weeks gestation. At this gestational
age lower uterine segment has been formed and started depleting.
Makin old gestation widening the lower uterine segment and cervix opening up. Thus berimplitasi
placenta in the lower uterine segment will experience a shift from the implantation site and will cause
bleeding. Fresh red blood, stem from sinus or uterine laceration marginali cynical of the placenta.
3.1.5. Therapeutic management
should be done in a hospital with surgical facilities. Before referred to, instruct the patient to
complete bed rest with facing left, do not perform sexual intercourse, avoiding the abdominal cavity
pressure eg coughing, straining as hard bowel movements)
Figure 35.3 Scheme Handling
Placenta previa
Put physiological NaCl infusion fluids. If not possible, give fluids proposals. Monitor blood pressure
and pulse rate of patients regularly every 15 minutes to detect the presence of hypotension or shock
due to bleeding. BJJ and also monitor the movement of the fetus.
event of shock, fluid resuscitation and immediately do blood trasfusi. If not resolved, try the optimal
rescue. When resolved, consider the gestational age.
Handling in the hospital was based on gestational age. If there are renjetan, gestational age <37
weeks, estimated fetal weight <2,500 g, then:
• If bleeding a little, take care until 37 weeks gestation, and then do gradual mobilization. Give
intravenous corticosteroids 12 mg per day 3 days salma
• If bleeding recurs, do PDMO. If there is a contraction, such as preterm labor deal with
the absence of renjetan, gestational age 37 weeks or more, an appraisal of fetal weight of 2,500 g or
more, do PDMO. If it turns previa, do perabdominan delivery. If not, try vaginal parturition.
3.1.6. Nursing
care is an essential service done by propesional care. For individuals, families and communities who
have health problems with the aim of helping them improve their health as much as possible in
accordance with the profession.
nursing care given to the client upon indication of placenta previa HAP will succeed when given
good nursing care and correct. Based on this, nurses are required to have knowledge about the
disease and action client what to do, other than that nurses must think and work dynamically.
kererawatan process used by nurses to solve the problems faced by the client, which is completely
based on scientific principles sertamempertimbangkan client as whole beings (bio, psycho, social,
and spiritual) and is unique.
Application of the nursing process ni clients are four stages: assessment, intervestasi and
evaluation.
1. Assessment
Assessment is a systematic approach to collecting and analyzing the data per group so as to know
the problem and the need for care of the client. The main purpose of the assessment is to provide an
overview of the state of continuous health plan that allows nurses to nursing home clients HAP. The
first step in the assessment of HAP clients are collecting data. The data collected are:
a. Common identity
b. Medical history
1. Medical history in advance
- There is the possibility of clients have experienced a history of such section is required uterine
curettage sasaria repetitive.
- Possible clients experiencing hypertension diabetes, hemophilia and infectious disease such as
hepatitis.
- likely have experienced abortion
2. Medical history now
- bleeding usually occurs for no reason
- Bleeding without pain
- Bleeding usually occurs in the third quarter or 20 weeks since.
3. Riwakat family health
- Possible family never had trouble another pregnancy.
- Chances are there families who suffer like this
- Possible family had experienced multiple pregnancies.
- Possible family suffer from hypertension diabetes, hemophilia and infectious diseases.
4. Riwayar Obstetrics
History of Menstruation / Menstrual
- Minarche: 12 th
- Cycle: 28 days
- length: ± 7 days
- Smells: fishy
- Complaints on menstruation: no menstrual pain complaints
5. History of pregnancy and childbirth
- multigravid
- Possible abortion
- Possible never done curettage
6. History nipas
- lochea Rubra
How it smells, fishy
- The number of times instead of 2 big duk
- About lactation
Colostrum there
c. Examination of vital signs
- temperature of the body, the temperature will increase if there is an infection
- blood pressure, would decrease if encountered any signs of shock
- Breathing, breathing oxygen if needs be met
- Nadi, pulse weakened if encountered signs of shock
d. Physical examination
- Head, such as color, condition and cleanliness
- Front, usually there cloasmagrafidarum, face looked pale.
- Eyes usually konjugtiva anemis
- Thoracic, usually vesicular breath sounds, kind of thoracoabdominal breathing
- Abdomen
• Inspection: there Strie gravidarum
• Palpation:
Leopoid I: The fetus is often not enough months, so it is still lower fundus
Leopoid II: Often found the location of errors
Leopoid III: The bottom of the fetus has not been dropped, if the location of the head usually head
still rocking or floating (floating) or stir above the pelvic .
Leopoid IV: The head of the fetus has not entered the pelvic
• Percussion: knee reflexes + / +
• Auscultation: fetal heart sounds can quickly slow. Normal 120 160
- normally in the vagina genetalia out pink base
- Extremities. Possibility of edema or varies. Possibility akral cold.
e. Investigations
- laboratory data, enabling a low Hb. Normal Hb (12-14gr%)
leokosit increased (Normal 6000-1000 mm3). Platelets decreased (normal 250
thousand - 500 thousand).
f. Socio-economic data
Plaesnta previa can occur at all levels of the economy but commonly occurs in middle-class, it is
also influenced by the level of education they have.
From the assessments described above can be arranged several nursing diagnoses that allow
clients HAP found in the placenta indication Precia among others:
1. The risk of recurrent bleeding associated with placental implantation effect on the lower uterine
segment (Susan Martin Tucker, et al 1988:523)
2. Disruption of daily needs associated with self-care disability. Secondary must bedrest (Linda Sell
Carpenito edisio: 326)
3. Risk of fetal care: vital distress associated with no strong blood perfusion to the placenta (Sell
Lynda Carpenito, 2000: 1127) post section.
4. Impaired sense of comfort: pain related to tissue trauma and abdominal muscle spasm (Susan
Martin Tucker, et al 1988: 624).
5. Activity intolerance related to physical weakness (Barbara Enggram: 1998:371)
6. The risk of infection associated with the opening of the entry of micro-organisms secondary to
cesarean surgery wound.
7. Anxiety related to lack of knowledge about the care and treatment (Susan Martin Tucker, et al
1988).
2. Planning
Planning of nursing is the next part of the nursing process. And the results of the assessment of the
nurses were able to determine a plan of action that will be performed on the client. This plan was
developed in accordance with client needs and solve problems. The plan of action of the diagnosis
are:
DX I
risk of recurrent bleeding associated with placental implantation effects on lower uterine segment
Objective:
The client did not experience recurrent bleeding
Intervention:
1. Encourage clients to limit perserakan
Rational: The movement that many can facilitate the release of the placenta that can bleed
2. Control of vital signs (BP, pulse, respiratory, temperature)
Rationale: By measuring the vital signs can be detected in a state of deterioration or progress of the
client.
3. Control vaginal bleeding
Rationale: By controlling the bleeding can be seen in the placental tissue perfusion changes so it
can take action immediately.
4. Anjurakan clients to report immediately if there are signs of bleeding more
Rational: Reporting signs of bleeding quickly can help to take immediate action to address the state
of the client.
5. Monitor fetal heart sounds
Rational: Heart rate over> 160 and <100dapat indicate fetal distress possible interference on
placental perfusion
6. Collaboration with the medical team to terminate the pregnancy
Rationale: With the end of pregnancy can overcome early bleeding.
DX II
Disorders of amniotic hariberhubungan with daily self-care disability must bedres Secondary
Objectives:
Meeting the needs of clients are met everyday
Intervention:
1. Development trusting relationships between nurses with clients using therapeutic communication
Rational: The client is expected to perform therapeutic communication cooperative in performing
nursing care.
2. Assist clients in meeting the basic needs of
Rational ith help clients needs such as bathing, BAB, BAK, so that clients' needs are met,
3. Involve the family in meeting the needs of
the Rational: By involving the family, clients feel at ease because it is done by their own families and
clients feel cared for.
4. Bring the tools needed client
Rationale: With closer kesisi tools clients can easily meet their own needs.
5. Encourage clients to tell the nurse to provide assistance
Rational: The nurse tells the client that needs can be met.
DX III
ambulatory fetal risk associated with inadequate placental perfusion darak to
Purpose:
Fetal Gawat not happen
Intervention:
1. Rest client
Rational: break through the possibility of removal of the placenta can be prevented
2. Encourage clients to be skewed to the left
Rationale: sleeping position lowers the inferior vena cava occlusion by the uterus and increase the
venous return to the heart
3. Encourage clients to breath in
Rational: With deep breathing can increase O2 consumption in the mother so that the fetus O2 are
met
4. Collaboration with physicians about oxygen delivery
Rationale: With O2 delivery can increase O2 consumption thus increasing consumption on the
fetus.
5. Collaboration with doctors about giving kortikosteroit
Rational: Korticosteroit can increase cell survival, especially the vital organs in the fetus.
DX IV
Impaired sense of comfort pain associated with tissue trauma and abdominal muscle spasm
Objective:
Feeling comfortable fulfilled
Intervention:
1. Assess the client's level of perceived pain
Rationale: By assessing the level of pain, when pain is perceived by clients can be served as a basis
and guide in subsequent nursing actions.
2. Explain to the client causes pain
Rationale: The client is expected to provide an explanation to the client can be adaptable and able to
cope with the pain that is felt clients.
3. Adjust the position of the client comfortable by stretching poses no wounds.
Rational: Stretching injuries can increase pain.
4. Distract the client of pain by referring clients to speak.
Rationale: By diverting the attention of the client, the client is not centered on the expected pain
5. Instruct and train clients relaxation techniques (deep breathing)
Rationale: With the expected influx breathing techniques oxygen to tissues smoothly with
expectations pain can be reduced.
6. Controls vital client sign
Rational ith control / menukur client vital signs can be seen setbacks or advances the state of
the client to take further action.
7. Collaboration with physicians in providing analgesic
Rational: Analgesics can suppress pain centers so nyeridapat reduced.
3.2. Placenta abruptio
3.2.1. Definition of
abruptio placenta is the insertion loss of the placenta prematurely
3.2.2. The etiology
is not known for sure. Possible predisposing factors are chronic hypertension, external trauma, short
umbilical cord, continues sudden decompression, anomalies or uterine tumors, nutritional deficiency,
smoking, alcohol consumption, the abuse of cocaine, as well as obstruction of the inferior vena kana
and ovarian vein.
3.2.3. Pathophysiology
triggered by the occurrence of abruptio plasentae perdarahanke in basal leaves are then split and
attached to a thin layer, forming a myometrium decidual hematoma that led to the release,
compression and eventual destruction of the placenta adjacent to that section.
decidual spiral arteries rupture causing a hematoma retroplasenta will decide more blood
vessels. Until more extensive removal of the placenta and reach the edge of the placenta. Because
the uterus remains berdistensi with the fetus, the uterus is not able to contract optimally to suppress
the blood vessels.Further blood flowing out DAPT release membranes.
3.2.4. Clinical Manifestations
• Anamnesis: usually in the third trimester bleeding, vaginal bleeding blackish color and a little
without pain until accompanied by abdominal pain, tense uterus, vaginal bleeding that much, DAK
shock intrauterine fetal death.
• Physical examination Vital signs be normal to show signs of shock.
• obstetric examination: uterine tenderness and tension, fetal parts difficult to assess, the fetal heart
rate is difficult to measure or do not exist, the amniotic fluid is reddish because of mixed blood.
3.2.5. Therapeutic management
should be done in a hospital with surgical facilities. Prior to the recommendation referred patients to
complete bed rest with facing to the left, do not do intercourse, avoiding the abdominal cavity
pressure (eg coughing, straining as hard bowel movements). Attach infusion of physiological
saline. If not possible, give fluids peronai.
Monitor blood pressure and pulse every 15 minutes to detect the presence of hypotension or shock
due to bleeding. BJJ and also monitor the movement of janin.Bila there rejatan, fluid resuscitation
and immediately do a blood transfusion. If not resolved, Strive Rescue optimal when resolved. Note
janin.Setelah rejatan overcome circumstances, consider Caesarean section when the fetus is still
alive or vaginal delivery is expected to last long. Rejatan if not insurmountable, try saving measures
that optimal.Setelah resolved shock and fetal death, see the opening. When more than 6 cm, then
break the amniotic infusion of oxytocin. If less than 6cm did not there rejatan sesarea.Bila section
and gestational age less than 37 weeks or estimated fetal weight less than 2,500 gr.Penanganan by
weight or lightness of the disease, namely:
a). Placenta abruptio Lightweight
• Ekspektatif, if there is no improvement (bleeding stopped, no uterine contractions, fetal life) with
bed rest and KTG series to overcome anemia, and wait for spontaneous labor.
• Active, if there is deterioration (bleeding continues, the uterus to contract, can threaten the mother /
fetus). Keep the vaginal parturition with amniotomy or oxytocin infusion whenever possible. If it
keeps bleeding, pelvic score of 5 or less labor is still long, do Caesarean section.
b). Abruptio placenta moderate / severe
fluid resuscitation
Overcome anemia with blood transfusion administration
vaginal parturition when it is expected to take place within 6 hours, if not can perabdominan
If there rejatan, gestational age of 37 weeks or more, estimated fetal weight of 2,500 g or
more. Think of parturition perabdominan when vaginal delivery is expected to last long.
Prognosis
Prognosis depends on the extent of maternal placenta detached from the uterine wall, the amount of
bleeding, the degree of blood clotting abnormalities, presence or absence of chronic hypertension or
preeclampsia, hidden or not bleeding. And the distance between the solusio plasentae to uterine
evacuation. Estimated risk of death ibi 0.5-5% and 50-80% fetal mortality.
3.2.6. Nursing
a). Assessment
1.) Biography Data Demographics
Age, gender, occupation and other identity mendukug.
2). Health History
past medical history (diabetes, renal failure and hypertension)
Family health history
and pregnancy history
gynecological history
Current Health Status
History nutritional status
3). Habits (smoking, use of drugs and alcohol)
4). Psychological status
5). Religious beliefs
6). Physical examination
Vital sign (BP, pulse, respiration and temperature)
Height and weight (before pregnancy and after pregnancy)
cardiovascular system, hypotension, tachicardi, and cyanosis)
urinary system (intake and output)
System integument ( edema, pale, cold skin)
reproductive system (examiner leopoid I - IV, increased uterine contractions. status cervix,
bleeding with blackish blood red color. Fundus uteri are higher).
Fetal Status (DJJ decreased, decreased fetal movement) .
7.) Investigations (ECG, ultrasound, laboratory blood {complete, urinalysis, and blood chemistry})
b). Nursing Diagnosis
1) Impaired tissue perfusion and shock commonly associated with hipovelemik.
2) Impaired tissue perfusion: bleeding associated with blood clotting disorders
3) Anxiety associated with possible negative effects of bleeding or pregnancy expenses
4) High risk of fetal distress associated with oxygen perfusion that inadequate placental
c). Nursing Intervention
1) Impaired tissue perfusion is generally associated with hypovolemic shock
goal: adequate network pefusi
Criteria:
vital signs within normal limits
skin warm and dry
Nadi adequate peripheral
Independent measures:
a.) Monitor vital signs (blood pressure, pulse, breathing, temperature, and peripheral pulse palpation
regularly)
R: permonitoran vital signs may show indications of recovery or decline in circulation
b.) Assess and record high increase in vaginal bleeding and uterine fundus.
R: For clue for further emergency measures
c.) Monitor intake and output to improve the circulation of fluid volume.
R: fluid intake (in parenatal) can help maintain circulatory volume
Collaborative action:
a. Administration of oxygen as indicated
R: Giving oxygen may improve circulation in the O2 network
b. Giving blood transfusion as indicated
R: giving blood transfusions to help circulation to the tissues
2). Tissue perfusion disorders: bleeding associated with blood clotting disorders
Objective: inadequate tissue perfusion and bleeding resolved
Criteria:
• General condition good mother
• normal blood clotting
• Vital signs within normal limits
• better blood circulation
Independent measures:
a. Assess and monitor abnormal vaginal bleeding
R: can be used as an indicator of the failure of blood clotting factor
b. Monitor blood circulation as well as sign DIC (lower levels of fibrinogen elasticity,
increased prothrombin, thromboplastin and the clotting of blood)
R: can intervene quickly and further action in accordance with the identified issues.
c. Giving trasfusi and blood components in accordance with the indications
R: Blood transfusions can help reduce clotting factors because of abnormal clotting.
d. Administration of drugs in accordance with the indications
R: administration of drugs to stop the bleeding and reduce blood clotting factors failure
3). High risk of fetal distress associated with inadequate oxygen perfusion of the placenta
goal: adequate perfusion of oxygen to the fetus
Criteria:
• normal DJJ (120-160 x / min)
• fetal oxygen requirements are met
• Uterine contractions abnormal
normal • HIS
• good fetal movement
Independent measures:
a) Monitor FHR and fetal movement
R: impaired placental perfusion may reduce oxygenation in the fetus, so that movement of the fetus
and abnormal FHR
b). Encourage the mother to maintain lateral sleeping position
R: lateral position can provide optimum circulation of the uterus and placenta
Collaborative action:
a). Provision of Oxygen as indicated
R: administration of oxygen will help the circulation of oxygen to the fetus to be adequate
b). Setting up the client to check the amniocentesis if needed
R: checks can be used as indicators of severity amniocentesis fetal emergency.
c). Prepare the client to do an emergency action such as Caesaria section
R: action section is one alternative to avoid the occurrence of fetal distress
CHAPTER IV
NURSING CARE OF
PATIENTS hyperemesis
4.1. Understanding
Hyperemasis gravidarum is excessive nausea and vomiting that day-to-day work and general
condition became worse. Nausea and vomiting are the most common disorders in pregnancy
trismeter 1.Approximately 6 weeks after the last menstrual period for 10 weeks. Approximately 60-
80% and 40-60% primigravida multigravid experience nausea and vomiting. However, these
symptoms become more severe in only 1 of 1,000 pregnancies.
4.2. Etiology
is not known for sure, but several factors have an influence, among others:
a) predisposing factors, namely pamigravida, hydatidiform mole and multiple pregnancy
b) organic factors, ie allergies, entry khorialis villi in circulation, metabolic changes due to pregnancy
and maternal resistance decreases
c) psychological factors
4.3. Pathophysiology
feeling nauseous due to increased estrogen levels. Continuous nausea and vomiting can lead to
dehydration, hyponatremia, hypochloremic., Decreased urine chloride. Next, there hemokosentrasi
which reduces blood perfusion and lead to the accumulation of substances kejaringan
toksit. Reserve carbohydrates and fat consumption causes fat oxidation is not perfect resulting in
ketosis. Hypokalemia due to excessive vomiting and excretion further augment hepatic marusak
frekuensu vomiting.Esophageal and gastric mucus membranes can tear (Mallory-Weiss syndrome)
causing gastrointestinal bleeding.
4.4 Clinical Manifestations
According to the severity of symptoms, hiperemisis grafidarum divided into 3 levels, namely:
a) Level I
Vomiting continued to affect the public, causing weakness, no appetite, weight loss and pain
apigastrium.Pulse frequency of patients increased by about 100 x / min, systolic blood pressure
dropped, reduced skin turgor, dry tongue and eyes sunken.
b) Level II
patients appear weak and apathetic, dirty tongue, small and rapid pulse, temperature and
sometimes rise slightly icterik eyes. Patient's weight down, arise hypotension, hemoconcentration,
oliguria, constipation, and bad breath acetone.
c) Level III.
Consciousness patients decreased from samnolen to coma, vomiting stops small and quick pulse,
temperature and blood pressure increased further to fall.
4.5 Treatment
If prevention does not work, then the necessary treatment that is:
a) Patients isolated in a quiet and sunny room with good air exchange. Calories provided
parenterally with 5% glucose in physiological fluids as much 2-3 liters a day.
b) diuresis always controlled to maintain fluid balance
c) If during the 24 hours the patient is not vomiting and general condition improved, try to give a bit
of food and minimaman gradually added.
d) Sedatives are given phenobarbital
e) recommended vitamin B1 and B6 plus
f) Provide psychological therapy to reassure patients and the disease can be cured menghilankan
fear of pregnancy and hyperemesis underlying conflict.
4.6. Nursing
Assessment
Assessment is a systemic approach to collecting data, classifying the data and analyze it so as to
know the problem and the need for client care. The main purpose of the assessment is to provide a
continuous picture of the client's state of health that allows nurses to plan nursing care to the client.
first step in the assessment of clients hyperemisis gravidarum is collecting data. Adapaun data that
will be collected are:
a) Medical History Data.
1. Health history data is now
At present medical history contained grievances felt by the client in accordance with the symptoms
on hyperemisis gravidarum are: nausea, vomiting continuously, feeling weak and exhausted, thirsty,
sour mouth, constipation and demam.Kemudian can also found decreased body weight, poor skin
turgor, electrolyte disturbances. The occurrence of oliguria, tachicardi sunken eyes and jaundice.
2. Medical history beforehand
• Possibility hioremisis gravidarum clients have experienced
before.
• Potential clients have experienced illness associated
with the digestive tract that cause nausea and vomiting.
3. Family health history
likely a history of multiple pregnancy in the family
b) The physical data of biological
data that can be found on the client hiperemisis gravidarum is enlarged mammary, mammary areola
hiperpikmentasi, there cloasma gravidarum, mucous membrane and lips dry, poor turgor, sunken
eyes and a bit of jaundice, the client looks weak and tired, tachycardia, hypotension, dizziness and
loss of consciousness was sour in the mouth.
c) menstrual history
• Possibility menarche age 12-14 years old
• Cycle 28-30 days
• Duration 5-7 days
• The number 2-3 times instead duk
• There may be a time of menstrual complaints such as pain, headaches, vomiting.
d) marital history
marital likely occur at a young age
e) History of pregnancy and childbirth
• Young Pregnant: Client dizziness, nausea, vomiting and no appetite.
• Old Pregnant: General examination of the client's weight, pressure
and blood levels of consciousness.
f) Data psychological
history is very important psychologically assessed in order to know the state of the soul of the client
with respect to the client's reactions and behavior towards pregnancy. Clients are labile mood,
irritability, anxiety, and fear of failure delivery, easy to cry, sad and disappointed to aggravate
nausea and vomiting. Patterns of self-defense used hiperemisis gravidarum clients depends on the
client's experience of pregnancy and the support of family and caregivers.
g) the social data economy.
Hiperemisis gravidarum can occur at all levels of the economy. But generally occurs in middle to
lower economic level, it is also influenced by the knowledge they have.
h) Data supporting
the supporting data obtained from the results of the laboratory examination of blood and
urine.Examination of the blood hemoglobin and hematocrit values were increased showing
homokonsentrasi related to dehydration. Urinalisa examination of the urine and have a slightly
higher concentration as a result of dehydration. The presence of acetone in the urine.
Nursing Diagnosis
From the assessments that have been described, there are several possible diagnoses
nursing namely:
1) Lack of fluid and electrolytes associated with excessive vomiting
and inadequate income (ireneM. Bobak, 1995: 637)
2) changes in nutrition, b / d of nausea and vomiting continuously (Irene M.Bobak: 638)
3) disruption comfort: epigastric pain b / d recurrent vomiting (Marie
S Jaffe. 1989 case 37)
4) Impaired elimination: constipation b / d of inadequate food intake (Marie S.
Jaffe. 1989 case 37)
5) Not effectively its patterns of self defense b / d psychological effects of pregnancy and
changes as a mother (Sharon J Reeder .1987 748 case)
6) Potential changes in fetal nutrition b / d reduced his food circulation to
the fetus ((Sharon J Reeder .1987 748 things)
Planning
1) Lack of fluid and electrolyte b / d of excessive vomiting and income are not adequately
Objective: The need fluid and electrolyte does not impaired
Interventions:
• Rest your clients in a comfortable
Rational: Resting metabolic energi.Kerja will reduce the need not increase so does not stimulate to
not occurrence of nausea and vomiting
• Monitor vital signs and signs - signs of dehydration
Rationale: By observing the signs of dehydration can know the general state of the client and the
extent to which the lack of fluid in the blood klien.Tekanan decreased, increased temperature and
increased pulse are signs of dehydration and hypovolemia
• Collaboration with physicians in the delivery of infusion
Rasoinal: Giving intravenous fluids to replace electrolytes lost the amount of fluid quickly
• Monitor infusion liquid droplets
Rational: Number and drip infusion handling can lead to excess or lack of fluids in the circulatory
system.
• Record intek and out put
Rationale: By knowing intek and unknown liquids output fluid balance in the body.
• After the first 24 hours suggest drinking each hour
Rational: Drinking can often increase revenue through oral fluid
2). Changes in nutrition; Less than keburuhan body b / d continuous vomiting
Objective: Nutritional needs are met
Intervention:
• Assess the nutritional needs of the client
Rationale: By knowing the nutritional needs of the client can be observed the extent of
the client's nutritional deficiencies and subsequent action.
• Observation of the signs of nutritional deficiencies
Rationale: To determine the extent of malnutrition due to vomiting
berlebiahan.
• After the first 24 hours give foods in small portions but often
Rational: small portions of food in the stomach may reduce compliance and reduce compliance and
reduces gastric and intestinal peristaltic work right facilitate the absorption of food.
• Provide food in warm and varied.
Rational: The food is hearty and varied to increase appetite.
• Give foods that are not fat and not greasy.
Rational: no fatty foods and oily reduce gastrointestinal stimuli that vomiting is reduced.
• Encourage clients to eat dry food and does not stimulate digestion (such as bread and biscuits)
Rational: dry food stimulates digestion and can reduce nausea and vomiting.
• Give clients the motivation to want to spend on food
Rationale: The client feel cared for and willing to spend food
• Weigh weight loss clients.
Rationale: With a weighing balance weight can be determined according to the age of pregnancy
and the nutritional effects.
3) Impaired sense of comfort: pain in the epigastric b / d vomiting are repeated.
Objective: Feeling comfortable fulfilled.
Intervention:
• Assess the level of pain.
Rational: to assess the level of pain to determine the level of pain on the client
and subsequent action.
• Adjust the position of the client with lebihtinggi head for 30 minutes after eating
Rationale: With the head higher to reduce the pressure on
gastroinstestinal thus reducing the vomiting recurs.
• Pay attention to oral hygiene sebelumdan clients after vomiting.
Rational: Good oral hygiene can lead to race and looked comfortable and vomiting is reduced.
• Distract the nice thing
Rationale: The client is expected to divert attention to forget the
pain caused by repeated vomiting.
• Encourage clients to rest and limit visitors
Rationale: With adequate rest and limit visitors can
add peace of clients.
• Collaboration of anti-emetic and sedative drugs by a doctor
Rational: anti-emetic drugs reduce vomiting danobat sedative to make the client
calm thus reduce pain.
4). Interference elimination: constipation b / d of inadequate food intake.
Objective: Elimination regularly.
Intervention:
• Assess the client's pattern of elimination
Rationale: To determine the daily elimination habits
• Encourage clients to eat fruits and vegetables
Rationale: By eating fruits and vegetables that can launch a lot of BAB.
• Encourage clients to spend a given diet.
Rationale: By spending a given diet food intek adequately and avoid constipation
• Encourage clients to drink plenty
Rational: The liquid that much to soften veses thus preventing complications
• Collaboration with physicians in the administration of laxatives.
Rationale: Giving laxatives can launch CHAPTER
5). Ineffectiveness of self-defense pattern b / d psychological effects of pregnancy and changes as a
mother.
Objective: Patterns of affective self defense
Interventions:
• Encourage the client to express his feelings directly to the pregnancy.
Rationale: The client can express their feelings known to the client's reaction to the pregnancy
• Listen attentively to customer complaints
Rationale: Clients feel diperhatikkan and not alone in facing the problem.
• Discuss with the client about the problems encountered and solutions to problems that do
Rationale: Through discussion can know client's pattern of self-defense in the face of the problem
• Assist clients in solving the problem mainly related to pregnancy
Rationale: By helping clients solve problems da [pat discover patterns of self defense effectively.
• Support clients if pemecahkan constructive problem
Rational: Will increase confidence in problem solving.
• Involve families in pregnancy client
Rational: Families are invited to cooperate in giving a boost to the client against pregnancy.
• Collaboration with psychiatrists if necessary
Rationale: To determine the possibility of more severe psychological factors as the cause of the
problem.
6). Potential changes in nutrition vetal b / d Reduced blood flow to the fetus and food
Objective: Fetal development is not compromised
Interventions:
• Explain to the client the importance of nutrition for the growth and development of the fetus
Rationale: In order for the client aware of the importance of nutrition for the fetus dank lien needs to
know nutrients.
• Check the Fundus uteri
Rationale: To determine the corresponding fundus with pregnancy
• Monitor fetal heart rate
Rational: The heart rate is still in a state of active normal and indicates the fetus is still in good
condition.
CHAPTER V
hematologic disorders
1. ANEMIA IN PREGNANCY
Both in developed countries and in developing countries, a person suffering from anemia bika called
hemoglobin concentration (HB) is less than 10 g%, severe anemia called, or if less than 6 g%, called
anemia gravis.
nonpregnant women has a normal value of 12-15 g% hemoglobin and hematocrit 35-54%. The
figures also apply to pregnant women. Therefore, examination, hematocrit and hemoglobin should
be routine blood tests during antenatal surveillance.
General causes of anemia are:
• Poor nutrition (malnutrition)
• Lack of iron in the diet
• malabsorption
• lost a lot of blood: the last delivery, menstruation etc..
• Chronic diseases: tuberculosis, lung, intestinal worms, malaria etc..
In pregnancy, blood volume increases (hyperemia / hipervolumia) because it occurs because the
blood thinning the blood cells are not comparable pertambahannya with blood plasma. Comparison
of the increment are:
• Blood plasma increased: 30%
• Blood cells increased: 18%
• Hemoglobin increases: 19%
of blood dilution Physiologically this is to help ease the work of the heart.
Effect of Anemia on Pregnancy, childbirth, and Postpartum:
• Miscarriage
• parturition Prematurus
• Inertia uteri and prolonged labor, weak mother
• Atonia uteri and cause bleeding
• Shock
• Afibrinogenemia and hipofibrinogenimia
• Infection in the intrapartum and postpartum
• In case of anemia gravis (Hb in below 4 g%) heart failure occurs, which
not only complicate pregnancy and childbirth, even fatal.
Effect of Anemia on the conceptus
Results conception (fetus, placenta, blood) need iron in large quantities for the manufacture of red
blood grain and growth, as many heavy metal. This number requires 1 \ 10 of all the iron in the
body. The occurrence of anemia in pregnancy depends on the amount of supplies of iron in the liver,
spleen, and bone marrow
long as they have sufficient supplies of iron, hemoglobin would not go down and if the supply is
exhausted, Hb will drop. It occurs in 5-6 months of pregnancy, when the fetus requires a lot of
iron. When anemia occurs, its effect on products of conception are:
• Miscarriage
• Jann death in utero
fetal death at birth •
• high perinatal mortality
• Prematurity
• Dapatterjadi congenital defects
• iron reserves are less
Classification of Anemia in pregnancy
• Iron deficiency anemia (62.3%)
• Megaloblastic anemia (29.05)
• hypoplastic anemia (8.0%)
• hemolytic anemia (sickle cell) (0.7%)
Iron deficiency anemia (62.3%)
of this type of anemia is usually normocytic and hypochromic shaped and most widely met. The
cause has been discussed above as a cause of anemia in general.
Treatment
Purposes iron for non-pregnant women, pregnancy, lactation and in the recommended are:
• FNB United States (1958): 12 mg-15mg-15mg.
• LIPI Indonesia (1968): 12mg-17mg-17mg.
Packaging of substances iron can be given orally or parenterally.
• Per Oral: ferosus sulfas or gluconate at a dose of 3-5 ferosus x0, 20mg.
• Parenteral: given if pregnant women do not hold oral administration or absorption in the
gastrointestinal tract is not good, given packing intra-muscular or intravenous. This pack include:
imferon, jectover, and ferrigen. The results are faster than orally.
Megaloblastic anemia
Megaloblastic anemia is usually macrocytic tau pernicious form. Penyebany is due to folic acid
deficiency, is rarely due to lack of vitamin B12. usually due to chronic malnutrition and infection
Treatment:
• 15-30mg of folic acid per day
• Vitamin B12 3 × 1 tablet per day
• sulvas ferosus 3 × 1 tablet per day
• in severe cases and oral medication slowly so that results can be
given a blood transfusion.
hypoplastic anemia
hypoplastic anemia caused by bone marrow hypofunction, forming red blood cells new, necessary
for diagnosis examinations:
• Blood banks complete
sternal puncture • Inspection
• Inspection reticulocytes and others.
Hemolytic anemia
Hemolytic anemia due to destruction or breakdown of red blood cells faster than manufacturing is
caused by:
• intracorpusculer factors: common in hemolytic anemia heriditer; thalassemia;
anemia sickle (crescent); hemoglobinopathy C, D, G, H, I; and parasismal nocturnal
hemoglobinuria.
• ekstrakorpuskuler factors: due to malaria, sepsis, metal poisoning, and
can with drugs; leukemia, etc.
The main symptoms are: anemia with blood picture abnormalities, weakness, fatigue and symptoms
of complications in the event of abnormalities in vital organs.
II LEOKEMIA AND PREGNANCY
Leokemia and pregnancy do not affect each other so, but in women leukemia, when pregnant,
should consult more regularly and more frequently, because of the threat to the pregnancy and her
spirit remains.
Against products of conception can occur abortion and prematurity. Danger of hemorrhage after
childbirth is quite large, as occurs in leukemia blood clotting disorders. The prognosis for the mother
and fetus are not well begiti.
Till sat there has been no satisfactory drugs against leukemia. Method of treatment are:
• Radiation: This is very membehayakan fetus in the womb, because it will cause teratogenic
abnormalities or fetal death in utero. When will be given radiation therapy and chemotherapy, you
should first products of conception removed (therapeutic abortion)
• Blood transfusions
• Chemotherapy and sirtotastika
• Anti metabilit
• Corticosteroids
Prevention
• Women should not become pregnant leukemia
• It is recommended to use contraception / tubectomy
Hemostatic FREEZING AND BLOOD DISORDERS
This disease is blood flow interruption or cessation of the blood vessels are open or injured.
There are 3 factors in the process of hemostasis:
1. Extra-vascular factors: factors tissues such as skin, muscle, subcutaneous and
other tissues.
2. Vascular factors, namely vascular wall
3. Intra vascular factors are: substances contained in blood vessels:
Implementation
Once the action plan next nursing action plans are implemented in real situations to achieve goals
that applied. Nursing actions should be detailed so that all maintenance personnel can perform well
in a predetermined time period.
implementation of the action in nursing, nurses can directly execute it on the client and the nurse can
delegate it to others who are still believed to be under the supervision of the nursing profession.
Evaluation
Evaluation of the nursing process is to assess the results of which are expected to change peilaku
clients and to determine the extent of the client's problem is resolved. Besides, nurses also conduct
a review of feedback or if goals have not been achieved and set yangh nursing process immediately
modified.
CHAPTER VI
CLOSING
5.1. Conclusions
Pre-eclampsia is a disease with signs of hypertension, edema and proteinuria arising from
pregnancy.This disease may occur in the third trimester of pregnancy, but may occur earlier
example karea molahidatidosa. (Winknjosastro, 1997:282)
antepartum haemorrhage (HAP) is bleeding from the genital tract that occurs between -28 to
mingggu pregnancies and early parturition. The main cause of antepartum haemorrhage are:
• Placenta previa.
• Solutio placenta.
Hyperemesis gravidarum is excessive nausea and vomiting that disrupted their daily work and
general condition became worse.
Hematologic disorder is a blood disorder which can be found in pregnant women can cause fetal
kematiaqn and the mother.
above four factors to look out for when it occurs during pregnancy and need early treatment.
5.2. Target
In doing nursing care to patients pre-eclampsia, antepartum haemorrhage, hyperemesis,
hematologic disorders in need of a complete assessment in order to establish nursing diagnoses
quickly and appropriately to the client so that the achievement of improvements in maternal and child
welfare.
b. Pemberian transfusi darah seperti yang ditunjukkan
R: memberikan transfusi darah untuk membantu sirkulasi ke jaringan
2). Perfusi jaringan gangguan: pendarahan yang berkaitan dengan gangguan pembekuan darah
Tujuan: perfusi jaringan yang tidak memadai dan perdarahan diselesaikan
kriteria:
• Kondisi Umum ibu yang baik
• pembekuan darah normal
• Tanda-tanda vital dalam batas normal
• sirkulasi darah yang lebih baik
Tindakan Independen:
a. Menilai dan memantau perdarahan vagina abnormal
R: dapat digunakan sebagai indikator kegagalan faktor pembekuan darah
b. Memantau sirkulasi darah serta menandatangani DIC (tingkat yang lebih rendah elastisitas fibrinogen, peningkatan protrombin, tromboplastin dan pembekuan darah)
R: dapat mengintervensi cepat dan tindakan lebih lanjut sesuai dengan permasalahan yang diidentifikasi.
c. Memberikan trasfusi dan komponen darah sesuai dengan indikasi
R: Transfusi darah dapat membantu mengurangi faktor pembekuan karena pembekuan abnormal.
d. Pemberian obat sesuai dengan indikasi
R: pemberian obat untuk menghentikan pendarahan dan mengurangi pembekuan darah kegagalan faktor
3). Resiko tinggi gawat janin berhubungan dengan perfusi oksigen yang tidak memadai dari plasenta
Tujuan: perfusi oksigen yang cukup untuk janin