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Disusun Oleh :
Nurul Maulifathul Jannah
CASE REPORT
NURSING CARE Mrs. N WITH
PARTUS VACUM EKSTRANSI IN ROOM OBSTETRI (B3O) RSUP Dr. KARIADI
SEMARANG
Assessment Date : 15th March 2010
Study Hours : 15.00 WIB
Room : B3O (Obstetric)
I. BIODATA
a. Patient Identity
Name : Mrs. N
Age : 26 years old
Sex : Female
Tribe / Nation : Java / Indonesia
Religion : Islam
Education : Senior High School
Occupation : Entrepreneur
Address : Kebonharjo, Tanjung Mas Rt 16/05 Semarang Utara
Date Admitted : 14th march 2010
Medical Diagnosis : DEEP TRANVEKSIS ARRET
Husband : Mr. S
Occupation : Entrepreneur
Age : 31 years old
Religion : Islam
Education : STM
REEDA signs
R : No redness
E : No red spots
E : No edema
D : lochea: alba
A : the wound still opened
XI EVALUATION
Name : Mrs. N
Age : 26 years old
Date/ Time Nursing Progress Note Sign
diagnoses
March, 16th, Comfortable S : Patient said that her breast wasn’t felt pain
2010 09.00 disturbances: pain after compressed and she also can adapt
r.t swelling of the with her pain now
breasts and there O : Patient looks relax
are wounds on the A : Problem resolved in part
perineum P : Suggest the patient to coompress her
breast with warm water in the morning
and afternoon