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Date / Hours : On May 4th 1. General Circumstances : Well Diagnosis : Ms “D” G1P0A0H0 1. Notify mother and family
2018 at 09.00 a.m 2. Awareness : Composmentis 10 Weeks Gestation With about mother and fetal’s
1. She said this was her first 3. Clinical data such as vital signs : Nausea, maternal and fetal condition and the results of the
pregnancy and her pregnancy B.P : 100/80 mm/hg condition are good. examination
entered 2 months Pulse : 80 x/i Evaluation :
2. She was complains of nausea Respiration : 24 x/i Problems : Maternal and fetal condition are
in the morning for the past 2 Temp : 36,50 C Nausea, often fatigue and dizzy. good with vital signs;
weeks. Weight : 50 kg B.P : 100/80 mm/hg
Height : 155 cm The Needs of : Pulse : 80 x/i
3. She said that She is very active 4. Physical Examination : 1. Information about Respiration : 24 x/i
but has noted more fatigue at Head : there is no maternal and fetal Temp : 36,50 C
the end of the day and she abnormalities conditon.
often dizzy. Face : Pale, no edema 2. Information about how 2. Gives the mother, information
4. She said She has not felt fetal Eyes : pale conjungtiva, to cope the nausea and that nausea and vomiting in TM
movement as of this time. the sclera is not the vommiting. 1 is a natural thing. Also Tell
jaundiced. 3. Information about the mother how to cope the
Ear : there is no balanced nutrision nausea and vommiting by eating
abnormalities 4. Information about take a a little bit of food but often, eat
Nose : there is no polip, rest pattern the cereal or biscuit, then avoid
and another 5. Continue taking prenatal eating oily foods and smelly
abnormalities vitamins sting , and on waking up do not
prominent nipples,
colostrum has not come 3. Tell the mother to consume