NORMAL ANC DOCUMENT (ASUHAN KEBIDANAN IBU HAMIL NORMAL)


MIDWIFERY CARE NORMAL PREGNANT WOMEN
IN NY. D AGES 25 YEARS G1P0A0Ah0  32  WEEKS GESTATION
PUBLIC HOSPITALS MUTIARA HUSADA CENTRAL LAMPUNG

Assessment
Date/Time       : 2 January 2015/ 15:00 WIB
MR Numbers  : 14/767
Ward   Room  : Delivery Room
Assessment by            : Evilia Nur Savitri

A.    Subjective Data
1.      Identity
Mother
Father
Name
Ny. A
Name
Mr. S
Age
25 th
Age
26 TH
Religion
Islam
Religion
Islam
Tribes
Java / Indonesia
Tribes
Java / Indonesia
Education
Senior High School
Education
Senior High School
Work
Housewife
Work
Entrepreneur
Address
Beji,Godean,Sleman
Address
Beji,Godean,Sleman




2.      Reason Coming
Mom said want to checkup
3.      Main Complaint
Mom said feel mild headache and swollen feet.
4.      History of Marriage
a.        
Marital Status
: Legitimate
b.       
Age Marriage
: 24 years old
c.        
To Marry
: First
d.       
Old Married
: 1 year



5.      Medical history
a.       Past Medical History
1.      Mom said never suffer from infectious diseases such as tuberculosis, hepatitis, measles, HV / AIDS
2.      The mother said he had never suffered from a hereditary disease such as asthma, heart disease, diabetes, hypertension
b.      Health History Now
1.      Mom says not suffering from infectious diseases such as TB, Hepatitis, measles, HIV / AIDS
2.      Mom says not suffering from hereditary diseases such as asthma, heart disease, diabetes, hypertension
3.      Mother said has never been hospitalized or surgery
c.       Family Health History
Mother said the family of the mother or her husband never be or have been suffering from cancer, heart disease, hypertension, diabetes mellitus, kidney disease, mental illness, congenital abnormalities, twin pregnancy, tuberculosis, epilepsy, and allergies based on the examination conducted by doctorsHistory of Obstetrics Gynecology
a.       Menstrual History
Menarche       : 12 years old
Cycles                        : 28 days
Long               : 7 days
Amount          : 3-4 times change the bandage, spots on day 1-2, fresh red on days 4-7. and back brown on days 5-7
Complaint      : No
The first day of the last menstrual period: 20 June 2014
b.      History of Pregnancy, Childbirth and Postpartum Ago
Mom said it was the first pregnancy
c.       Pregnancy History Now
Pregnant To
: 1
Age Pregnancy
: 32 Weeks
Due date
: 27 March 2015
Delivery Plan
: The Midwife
Blood donors
: Sister (Nava)
Transport
: Car
Cost
: Labor savings
6.      History KB
Mother said she had never used KB.
7.      Dialy Custom Pattern
Custom Pattern
Before Pregnancy
During Pregnancy
Complaint
a.       Nutrition Eat and drink
Eating 3 meals / day, rice, side dishes, vegetables. Drink 8 glasses of water, sweet tea
Eating 3-4 times / day, rice, side dishes, vegetables, a little snack. Drink 8 glasses of water, sweet tea, and milk
No problem
b.      Elimination

urination
2-3 times, dense, brownish
1 time, a bit soft, tawny
6-7 times,
No problem
defecate
7-8 times, lot, clear color
much, sometimes slightly yellow color clear

c.       Activity
Doing housework
Doing housework as usual, but reducing the heavy work
No problem



d.      personal hygiene
Shower 2 times / day, brush your teeth two times, three times a week to wash, change clothes 2 times
Shower 2 times / day, brush your teeth two times, three times a week to wash, change clothes 2-3 times
No problem
e.       Break
Occasional nap, sleep 7-8 hours a night
Naps 1-2 hours of sleep a night for 7-8 hours
No problem
f.       sexual patterns
3-4 times a week
1-2 times in a week
No problem
8.      Data Psychosocial, Cultural and Spiritual
a.       Psychosocial   : Mom said this pregnancy was planned and eagerly anticipated
b.      Cultural          : Mom said that decision to the messenger carried by deliberation
c.       Spititual          : Mother said about following ritual prayers five times,     Recictation every friday
9.      Knowledge Data Client
Mom said  not so familiar with the pregnancy because the first time
10.  Environment
Neighborhood      : Clean and tidy, far from the crowds
Living together    : Husband
Type of dwelling  : permanent building

Komentar

Postingan populer dari blog ini

CRITICAL THINKING INTERPROFESSIONAL EDUCATION (IPE)

ETIKA BERKOMUNIKASI DENGAN DOSEN (MAKALAH ETIKA UMUM)

Mini Cex (Mini Clinical Evaluation Exercise) dan Form Mini Cex