WOMAN OF NON-NORMAL PREGNANT WOMAN

No. Register :
Log in RS / PKM / BPM Date / Time : 01-04-2017 / 13.30 WIB
Maintained in the room : Check room

I. DATA ASSESSMENT.
A. BIODATA
MOTHER HUSBAND
1. Name : Ny.D Mr.A
2. Age : 33 Years 36 Years
3. Religion : Islam Islam
4. Tribes : Java / Indonesia Java / Indonesia
5. Education : SMA SMA
6. Work : Housewife Daily Labor
7. Address : SawahLunto SawahLunto

B. Subjective data
1. Reason came / treated
Mother said want to check the content because it was too late menstruation
2. Main complaint
Mom says her body is limp and nausea vomiting
3. Menstrual History
Menarche : 13 years old Cycle : 28 Days
Long : 7 days Regular : Regular
Nature of blood : Encer Complaint : There is no
4. Marital History
Marital status : Sah Married to : One
Long : 11 years old Age of marriage the first time : 22 years
5. Past pregnancy, childbirth & postpartum history.

Pregnant LABOR NIFAS

To Date Age Type Helper Complications JK BB lactation compl
Pregnancy Labor Born ication
s
1 2006 38 normal Midwife There is no L 3000 yes Ther
Sunday g e is
no
2 2010 39 normal Midwife There is no P 3200 yes Ther
weeks g e is
no
3 THIS PRESENT

6. History Contraception used

NO Type PAIR FREE

Contraception
Date by the Complaint Date by The Reason
place place

1 IUD 2011 midwife BPM There is 2015 midwife BPM Add a

no child

7. Pregnancy History Now

a. HPHT : 11-02-2017 TP : 17-11-2017
b. First ANC gestational age : 7 +4 weeks
c. ANC visit
 Trimester 1
Frequency : 1 time
Complaint : Lethargy and Nausea Vomiting
Complications :There is no
Therapy : 1x1 B6 and 1x1 anelat
 Trimester II
Frequency : 0 times
Complaint :
Complications :
Therapy :
 Trimester III
Frequency : 0 times
Complaint :
Complications :
Therapy :

d. TT immunization : 5 times
TT I : Date 05-05-2006
TT II : Date 05-06-2006
TT III : Date 05-12-2006
TT IV : Date 05-12-2007
TT V : Date 05-12-2008
e. Fetal movement for 24 hours (in a day)
Mom says she has not felt the fetal movement

8. Medical history
a. Diseases that have / are suffered (contagious, decreased, chronic)
Mother says never / is suffering from infectious disease (PMS, TBC), decreased (DM,
Hepatitis) and chronic (Heart)
b. Diseases that have / are suffered family (contagious, decreased, chronic)
Mother says never / is suffering from infectious disease (PMS, TBC), decreased (DM,
Hepatitis) and chronic (Heart)
c. History of twin ancestry
Mom says she has no history of twinning
d. History of Operation
She said she had just had a hemorrhoid operation
e. History of drug allergy
Mom says she has no history of drug allergies
9. Pattern of need fulfillment
Before Pregnant While Pregnant
a. Nutrition
Eat
Frequency : 3x / day Frequency : 2x / day
Type : Rice, vegetables, side dishes Type : Rice, vegetables, side dishes
Portion : 1 plate Portion : ½ dish
Abstinence : no Abstinence : there is no
Complaint : there is no Complaint : there is no
Drink
Frequency : 7-8 x / day Frequency : 7-8 x / day
Type : Water, Tea Type : Water, milk
Portion : 2 glasses Portiont : 1-2 glasses
View it : there is no Abstinence : There is no
Complaint : no Complaint : There is no
b. Elimination
CHAPTER
Frequency : 1 x / day Frequency : 1 x / day
Color : Brownish Color : Brownish
Consistency : Soft Consistency : Soft
Complaint : There is no Complaint : There is no
BAK
Frequency : 5-7 x / day Frequency : 8-10 x / day
Color : Yellowish Color : Yellowish
Complaint : there is no Complaint : there is no
c. Break
Siesta
Long : 1-2 hours / day Long : 1-2 hours / day
Complaint : there is no Complaint : there is no
Sleep at night
Long : 7-8 hours / day Long : 7-8 hours / day
Complaint : there is no Complaint : there is no
d. Personal Hygiene
Bath : 2 x / day Bath : 2 x / day
Change dress : 2 x / day Change dress : 2 x / day
Brush your teeth : 3 x / day Brush your teeth : 3 x / day
Shampooing : 5 x / week Shampooing : 5 x / week
e. Sexuality patterns
Frequency : 4 x / week Frequency : 3 x / week
Complaint : there is no Complaint : there is no
f. Activity pattern (related to physical activity, sport)
Mom says in her daily life it is sweeping, washing clothes, washing dishes, mopping floors,
and cooking

10. Habits that interfere with health (smoking, drinking herbs, alcoholic beverages)
Mother says no smoking habits, drinking herbs, and drinking alcoholic beverages.
11. Psychosocial, spiritual and economic data (acceptance of mother / husband / family
against birth, family support, relationships with husband / family / neighbors, infant care,
worship activities, social activities, family economic conditions.
a. Mother said no igin pregnant again because the new operation
b. Mom says relationships with family, husband, and neighbors are fine
c. Mother said doing worship activities at home
d. Mother says the economy is sufficient
12. Maternal knowledge (about pregnancy, childbirth, childbirth)
Mother said already know about pregnancy, childbirth, and childbirth through previous
experience.
13. Influential environments (around homes and pets)
Mom says the neighborhood around her house is clean but there are often cats that enter her
house.

C. Objective Data
1. General examination
General situation : Good
Awareness : Composmentis
Emotional Status : Stable
Vital Signs
Blood pressure : 100/60 MmHg Pulse : 84 x / min
Respiratory : 16 x / min Temperature : 36.8 0 C
BB : 56 kg TB : 155 cm
2. Physical examination
Head : no tenderness, clean, no odema
Face : clean face and no odema
Eye : pink conjunctiva, white sclera, and normal pupil
Nose : there is no blockage in the nose, no polyps and secretions
Mouth : clean teeth and no holes, pink palate
Ear : there is normal dirt and hearing
Neck : no enlargement of the tyroid gland and no lymph nodes odema
Chest : No tenderness
Breast : Breasts are hyperpigmented and enlarged
Abdomen : There is a linea gravidarum, and striae gravidarum palpable ballotment

Palpate
Leopold 1 : Unprotected fetus on the mother's fundus
Leopold 2 : Unprotected fetus on left and right side of mother's belly
Leopold 3 : Unprotected the fetus at the lowest part of the mother's abdomen
Leopold 4 : Not yet known the fetus has entered the pelvis or not

Osborn Test :
McDonald's examination
TFU : Not yet felt TBJ : Not yet felt
Auscultation
DJJ : Not yet heard
Upper extremity : Full finger symmetry, no edema
Lower limb : Full finger symmetry, no edema and varicose veins
Outside genetalia : Are not done
Pelvic examination : Are not done
(if necessary)
3. Supporting investigation Date: 04-04-2017 Hit : 15.30 WIB
Performed pp test
4. Supporting data
The pp test result is positive

II. DATA INTERPRETATION

A. Diagnosis Midwifery
Ny.W age 33 years G3P2AOAh2 gestational age 7 + 4 weeks with normal pregnancy trimester
1
Basic Data :
DS :
1. Mother says 33 years old
2. Mom says this is her third pregnancy
3. Mother told HPHT February 11, 2017
4. Mom says feeling weak and nausea vomiting
DO :
General situation : Good
Awareness : Composmentis
Blood pressure : 100/60 MmHg Pulse : 84 x / min
Respiratory : 16 x / min Temperature : 36.8 0 C
UK : 7 + 4 weeks BB : 56 Kg

B. Problem
There is no
Basic Data : there is no

III.IDENTIFICATION AND ANTICIPATION OF POTENTIAL DIAGNOSIS

There is no

IV.IMMEDIATE ACTION, COLLABORATION & REFERRAL

A. MANDIRI
There is no
B. COLLABORATION
There is no
C. REFERENCE
There is no

V. PLANNING
Date : 04-04-2017 Hit : 15.35 WIB
1. Notify the mother of the results of the examination
2. Notify the mother of the complaint and how to resolve it
3. Tell the mother to eat nutritious food
4. Motivate the mother to accept her pregnancy
5. Give mothers drug therapy
6. Encourage the mother to re-visit
7. Document the results of the examination

VI.IMPLEMENTATION
Date : 04-04-2017 Hit : 15:37 hrs
1. Notify the mother of the examination that is:
Blood pressure : 100/60 MmHg Pulse : 84 x / min
Respiratory : 16 x / min Temperature : 36.8 0 C
BB : 56 Kg
2. Tell the mother the cause of the complaints are due to changes in hormones in early
pregnancy so that mothers feel nausea vomiting, how to cope with eating a little but often and
do not eat stinging foods, while how to overcome the complaints tired of adequate rest, if
complaints are not lost after rest, ex
3. Tell moms of nutritious food such as meat, vegetables, beans, and eat rice substitute
foods such as bread, cereals, biscuits.
4. Giving spirit to the mother to accept her pregnancy, because it is a gift of god omaha.
5. Gives the mother a 1x1 B6 tablet and 1x1 anelat
6. Encourage the mother to visit one more month on 04 March 2017 or if there is a
complaint.
7. Document the results of the action

VII. EVALUATION
Date : 04-04-2017 Hit : 15:45 hrs
1. Mother already knows the results of her examination
2. Mother already know the cause of the complaint and already know how to overcome
them.
3. Mothers already know about the nutrition of trimester 1 pregnant women
4. Mother has started to accept her pregnancy
5. Mother has been given drug therapy
6. Mother is willing to re-visit
7. The result of action has been documented