ASKEB: ANC NORMAL (MIDWIFERY CARE NORMAL PREGNANT WOMEN)

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