ASKEP MELAHIDATIDOSA

ASUHAN KEPERAWATAN

A.     Pengkajian meliputi :

1. Observasi / inspeksi,                6. Abdomen

-          auskultasi,                                7. Fundus

-          palpasi dan                              8. Lochea

-          perkusi                         9. Eleminasi

2. Penampilan umum                               10.Perinium
3. Nadi dan tekanan darah                       11.Episiotomi
4. Temperatur                                          12.Insisi SC
5. Penyudara                                            13.Hemoroid
6. Abdomen                                             14. Ektermitas

B.     Ng Diagnosis

1. Altered bowel elemination R.to decreased bowel motility and abd.muscletone, dehydration, painful defecation
2. Altered patterns of urinary elemination R.to PP diuresis and urinary retention from post delevery edema
3. Pain related to uterine consiotomy, laceration hemoroid breast engorgement, surgical inc
4. Impaired skin intergrity R.to surgical incision or laceration
5. Risk for infection R.to impaired skin integrity and tissue trauma from childbirth
6. Fluid volume difisit R.to Blood loss
7. Altered nutrition : less than body requirements R.to incerease need eith lactation
8. Sleep pattern disturbance R.to physical discomforts or to the newborns feeding needs
9. Situational low self esteen R.to lack of knowledge about physilogic processe, self care and newborn care, altered body image, emotional moodiness, and changes in personal and role identities

C.     Perencanaan dan Pelaksanaan

Monitoring dan Supporting Status fisiologis Ibu meliputi :

1. Tanda Umum
2. Mon. lechea
3. Mon ekst. (thromboflebitis)

Peningkatan Fungsi Tubuh :

1. Pemulihan fungsi kandung kemih
2. Pemulihan fungsi saluran cerna
3. Peningkatan istirahat dan kenyamanan dari kont. Uterus
4. Ketegangan otot dan kelelahan nyeri post SC
5. Perawatan perinium
6. Perawatan payudara

Adaptasi Psikologi

1. Gambaran tubuh
2. Konsep diri

Promosi Kesehatan dengan H. E khususnya pada early PP :

1. Penyuluhan tentang :

-          Senam nifas

-          Breast care

-          Perawatan bayi

-          Perencanaan pulang

2. Kontrasepsi dam seksualitas