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1. Assessment

Assessment is stage beginning And base main from process nursing.

Stage assessment consists on collection data And formulation need or

problem client. Data Which collected covers biological, psychological,

social and spiritual data. Nurse's abilities expected in do assessment is

have awareness/view self, ability observe with accurate, therapeutic

communication skills and always being able to respond in a way effective.

On basically objective assessment is gather data objective and subjective

from the client

At the assessment stage, researchers used the Maternal nursing model

Roles Attainment-Becoming a Mother on post partum namely:

a. Identity client

Covers Name, place date born, religion, ethnic group nation,

education final, job, address, income per month.

b. Anticipatory

1) Health Status: reason for visit, visit, main complaint, medical

history.

2) History obstetrics And gynecology : History period, history

marriage, family planning history, history of previous pregnancy &

childbirth, history pregnancy & delivery now,

3) Fulfillment need base man : nutrition, elimination, oxygenation,

activity and rest.

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4) Support social : support emotion, support information, support

physique, award support.

5) Function family

6) Assessment culture

7) Stress

8) Inspection physique Mother

- Eyes: the conjunctiva is normally pink and the sclera normally

colored white

- Mammary: breasts are symmetrical or not, nipples are clean and

stand out or No. Hyperpigmentation areola or No, colostrum

already out or not yet.

- Abdomen: whether there are SC scars or not, whether there are

lines or No, striae There is or not

- Genitalia: clean or not, edema or not, redness or No, perineum

is present epiostomy scar or not

- Extremities : edema or No And varicose veins or No

c. Formal

1) History labor At the moment

2) Bonding attachments with gray scoring

3) Assessment baby

4) Aspect psychosocial Mother

5) Role Father during and after birth

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d. Informal

1) Person Which involved in maintenance baby.

2) Role in maintenance baby.

3) Experience in maintenance baby.

4) Hope For maintenance baby Which will come.

e. Personal

1) View Mother to his role.

2) Experience period then that influences the role Mother.

3) Believe self in operate role.

4) Achievement role.

2. Diagnosis Nursing

According to (Wayan, 2017), (Arma, 2015), and (SDKI Working

Group Team DPP PPNI, 2017) nursing diagnosis in Primiparous Post

Partum Mothers And Newborn baby is:

 Mother's Diagnosis:

1) Painful I Relate With Agent Physical Injury.

2) Breast-feed No Effective Relate With Inadequacy Supply breast

milk.

3) Disturbance Pattern Sleep Relate With Lack of Control Sleep.

4) Deficit Knowledge Relate With Not enough Exposed Information.

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5) Risk Infection Be marked With Inadequacy Defense Body

Primary.

6) Attachment Disorder Risk Is Characterized

by Worry Operate Role as a Parent.

 Diagnosis Baby :

1) Risk Aspiration Be marked With Immaturity Coordination

sucking, Swallow And Breathe.

2) Risk Infection Be marked With Inadequacy Defense Body

Secondary (Immunosuppression/Immune System).

3) Risk Deficit Nutrition Be marked With Inability Digest Food.

3. Intervention Nursing

Nursing interventions are all treatments carried out by nurses

based on knowledge and clinical judgment For reach outer ( outcome)

Which expected (Team Working Group SIKI DPP PPNI, 2018).

Application outer nursing with use third components of nursing

outcomes, namely Labels, Expectations and Results Criteria. Method

Which can done is as following (Team Working Group SLKI DPP PPNI,

2019) :

1) Method Documentation Manual/written

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After carrying out nursing intervention for a certain time so

Expected Nursing Outcomes with criteria results :

a. Criteria 1 (Results)

b. Criteria 2 (Results)

c. And so on.

2) Method Based Documentation Computer

After carrying out nursing intervention for a certain time Outer

Nursing Expectations with outcome criteria:

a. Criteria 1 (Score)

b. Criteria 2 (Score)

c. And so on.

Action components, which are carried out in nursing interventions

consists on Observation, Therapeutic , Education And Collaboration

(Team Working Group Siki DPP PPNI, 2018)

The following interventions can be carried out according to

intervention standards Indonesian nursing (PPNI DPP Siki Working Group

Team, 2018), in Mrs. Post Partum Primipara and New Baby Birth is:

 Intervention Mother :

1) Painful I (D.0077)

a. Objective general : After done intervention nursing during

specific time expected pain level decrease.

b. Criteria results :

a) Patient report complaint painful reduce

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b) Complaint painful the grimace decreases

c) Patient show attitude protective decrease.

d) Patient No looks nervous.

c. Interventio
n:

Management Painful (I.08238)

a) Observation

(1) Identify location, characteristics,

duration, frequency, intensity painful.

(2) Identification scale painful.

(3) Identification factor Which aggravate And lighten up

painful.

(4) Identification knowledge And confidence about painful

(5) Monitors success therapy complementary Which

Already given.

b) Therapeutic

(1) Give technique Norpharmacological For reduce flavor

painful

(2) Facilitation Rest And Sleep

c) Educati
on

(1) Explain reason, period And trigger painful.

(2) Explain strategy relieve painful

(3) Advise monitor painful in a way independent.

(4) Teach technique non-pharmacological For borrow painful.

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d) Collaboration

Collaboration giving analgesic, If need

2) Breast-feed No Effective (D.0029)

a. Objective General : After done intervention nursing during time

certain expected status breastfeeding improves.

b. Criteria Results :

a) Attachment baby on breast Mother increase.

b) Ability Mother positioning baby with Correct increase.

c) Emission of breast milk increase

d) Supply breast milk adequate increase.

e) Patient report breast No swollen

c. Intervention :

Counseling Lactation ( I.03093 )

a) Observation

(1) Identification problem Which Mother experience

during process breast-feed.

(2) Identification desire and goals breast-feed.

(3) Identification circumstances emotional Mother moment

will done counseling breast-feed.

b) Therapeutic

(1) Use technique hear active.

(2) Give praise to behavior Mother Which Correct.

c) Education
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Teach technique breast-feed right in accordance need Mother.

3) Disturbance Sleep Pattern (D.0055)

a. Objective General : after done action nursing pattern Sleep

increase.

b. Criteria results :

a) Nervous decrease

b) Complaint difficult Sleep decrease

c) Pattern sleep improves

c. Intervention :

Management Painful (I.08238)

a) Observation

(1) Identification location, characteristics, duration,

frequency, intensity painful.

(2) Identification scale painful.

(3) Identify aggravating and mitigating factors painful.

(4) Identification knowledge And confidence about painful

(5) Monitors success therapy complementary Which

Already given.

b) Therapeutic

(1) Give technique Norpharmacological For reduce flavor

painful

(2) Facilitation Rest And Sleep

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c) Education

(5) Explain reason, period And trigger painful.

(6) Explain strategy relieve painful

(7) Advise monitor painful in a way independent.

(8) Teach technique non-pharmacological For borrow painful.

d) Collaboration

Collaboration giving analgesic, If need

4) Deficit Knowledge (D.0111 )

a. goal : after carrying out nursing

actions expected the level of knowledge increases

b. Criteria results :

a) behavior in accordance recommendations increase

b) verbalization interest in study increase

c) ability explain knowledge about something topic increase

d) ability to describe previous experiences

Which according to the topic increases

e) behavior in accordance with knowledge increase

f) question about problem Which faced decrease

g) perception Which wrong to problem decrease

h) undergo inspection Which No appropriate decrease

i) behavior improved

c. Intervention :
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Education Health (I.12383)

a) Observation

(1) Identify readiness and ability to accept

information

(2) Identification factors Which can increase And lower

behavioral motivation clean life and healthy

b) Therapeutic

(1) Provide material And medla education health

(2) Schedule education health social agreement

(3) Give chance For ask

c) Education

(1) Describe the risk factors that may

influence it health

(2) Teach behavior life clean And Healthy

(3) Teach strategies that can be used to

increase clean and healthy living behavior

5) Risk Infection (D.0142)

a. Objective General : After done intervention nursing during time

certain expectations infection rates decrease.

b. Criteria Results

a) There isn't any bunches - signs infection ( Fever, Pain,

Redness And Swollen).

b) Rate cell blood white improved.

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c. Intervention

Infection Prevention ( I. 14539 )

a) Observation

Monitors sign and symptoms local infection and systemic.

b) Therapeutic

(1) Wash hand before And after contact with patient And

patient environment.

(2) Keep it up technique aseptic on patient risky tall.

c) Education

(1) Explain sign and symptoms of infection

(2) Teach method wash hand with Correct.

(3) Teach method check condition wound.

(4) Advise increase intake nutrition.

6) Risk Disturbance Attachment (D.0127)

a. Objective General : After done intervention nursing during A

certain time is expected for the ability to interact between mother

and baby increase.

b. Criteria Results

a) Patient show enhancement verbalization feeling positive to

baby.

b) Patient show enhancement behavior kiss baby, smile on

baby, do contact eye with baby,

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speak with baby, speak to baby as well as respond with

baby signal.

c) The patient showed improvement in

carrying the baby to breastfeed.

c. Intervention :

Promotion Attachment ( I.10342 )

a) Observation

(1) Monitors activity breast-feed.

(2) Identification ability baby suck And swallow breast

milk.

(3) Identification breast Mother.

(4) Monitors attachment while breastfeeding

b) Therapeutic

Discuss with Mother problem during process breast-feed.

c) Education

(1) Teach Mother supports everything body baby.

(2) Advise Mother let go clothes part on so that baby can

touch breast Mother.

(3) Teach Mother so that baby Which approach toward

breast Mother from the bottom.

(4) Advise Mother For hold breast use his finger like the

letter " C”.

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(5) Advise Mother For breast-feed on moment mouth baby

open wide so that areola can enter with perfect.

(6) Teach Mother recognize sign baby Ready breast-feed.

 Intervention Baby :

1) Aspiration Risk (D.0006)

a. General Objective: After carrying out nursing interventions

during time certain expectations respiration increase

b. Criteria Results :

a) Reflex swallow increase

b) Business swallow increase

c) Frequency choked decrease

c. Intervention :

Prevention Aspiration ( I.01018 )

a) Observation

Monitors status Respiratory.

b) Therapeutic

Keep it up patent road breath.

c) Education

Teach strategy prevent aspirations.

2) Risk Infection (D.0142)

a. Objective General : After done intervention nursing during time

certain expectations infection rates decrease.

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b. Criteria Results

a) No There is bunch – sign infection ( Fever, Painful, Redness

And Swollen).

b) Rate cell blood white improved.

c. Intervention

Infection Prevention ( I. 14539 )

a) Observation

Monitors sign and symptoms infection local and systemic.

b) Therapeutic

(1) Wash hand before And after contact with patient And

patient environment.

(2) Keep it up technique aseptic on patient risky tall.

c) Education

(1) Explain sign and symptoms of infection

(2) Teach method wash hand with Correct.

(3) Advise increase intake nutrition.

3) Risk Deficit Nutrition

(D.0019)

a. Objective general: after done action nursing expected

expectations nutritional status improves

b. Criteria results :

a) Strength muscle swallow increase

b) Serum albumin increase

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c) Knowledge about standard intake nutrition Which

appropriate increase

d) Diarrhea decrease

e) Heavy body improved

f) Frequency Eat improved

g) Noisy intestines improve

3) Intervention :

c. Management nutrition (I.03119)

a) Observation

(1) Identification status nutrition

(2) Identification allergy And intolerance food

(3) Identification need calories And type nutrients

(4) Monitors intake food

(5) Monitors heavy body

(6) Monitors results inspection laboratory

b) Therapeutic

(1) Give food tall fiber For prevent constipation

(2) Give food tall calories And tall proteins

c) Education

(1) Advise sitting position, If capable

(2) Advise diet Which programmed

d) Collaboration
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Collaboration with expert nutrition For determine amount

calories And types of nutrients needed, if necessary

4. Implementation Nursing

Implementation nursing is series activity Which done by nurse For

help client from problem status health faced to a better health status that

describes criteria expected results (Potter, 2011)

Component implementation stage :

a) Action nursing independent.

b) Action Educative nursing.

c) Action nursing collaborative.

d) Documentation action nursing And response client to

nursing care.

5. Evaluation Nursing

Evaluation is stage final from process nursing Which aims to

assess the final results of all nursing actions Which have been done

(Bararah, 2013).