CHAPTER I

INTRODUCTION

A. Background
So far, postpartum bleeding has been the cause
the death of the mother, however with the increased supply of blood and system

references, infections become more prominent as the cause

maternal death and morbidity (Saleha, 2009).
According to the Population Census Inter-Census Survey (SUPAS) 2015, mortality

Maternal (MMR) refers to the death of women during pregnancy or death

within a period of 42 days from the termination of pregnancy regardless
the duration of pregnancy or place of delivery, namely death caused by
because of her pregnancy or its management, but not due to other causes
like accidents, falls, and others. The 2010 population census results
showing the Maternal Mortality Rate (MMR) in Indonesia is 346
There were 346 female deaths during pregnancy and childbirth.
or the postpartum period per 100,000 live births. The MMR in 2015 is lower than
The population census result of 2010 was 305/100,000 live births.
Puerperal infections cause morbidity and mortality for mothers.
postpartum. The degree of complications during the puerperium varies. Postnatal care
needed during the postpartum period because it is a critical time for both the mother
or from babies. It is estimated that 60% of maternal deaths due to pregnancy occur
After childbirth, 50% of maternal deaths occur within the first 24 hours.
postpartum (Saifuddin, 2006).
The commonly reported postpartum morbidity is infection.
the vagina causes uterine infections that can lead to complications
other or pose a threat to the mother's life. Postpartum morbidity has not yet
acknowledged due to several factors including cultural restrictions, education,

socio-economic and lack of access to healthcare services (Saifudin,

2006).
General management during the postpartum period includes anticipating every

conditions (predisposing factors and issues in the delivery process) that can

1
 continues to become an obstacle or complication during the postpartum period, providing

rational and effective treatment for mothers experiencing puerperal infection,

continuing the observation and treatment of issues or infections that
identified during pregnancy or childbirth, do not return the client
if the critical time has not passed, provide notes or instructions for
home self-care, symptoms to watch out for and must
obtain immediate assistance and provide oral or IV hydration
sufficiently (Saifuddin, 2006).
Knowledge and understanding of infections in postpartum mothers
very important for students in the nursing field to be able to
knowing the infections that occur in postpartum mothers, how to prevent them,
also skills to care for mothers experiencing postpartum infections.
Therefore, we prepared a paper titled 'Care'
Nursing in Postpartum Maternal Infection Cases.
B. Problem Formulation
The formulation of the problem that will be discussed in this paper.

namely: What nursing care should be provided in the case

postpartum maternal infection?

C. Objectives of Nursing Care in Postpartum Infection Cases

The purpose of providing nursing care in this case is
postpartum infection in mothers is:
General Purpose
To understand the concept of postpartum infection theory and care
nursing care for patients with normal postpartum includes assessment,
intervention, implementation, and nursing evaluation.
2. Specific Objectives

a. Understanding the basic concepts of postpartum infection (definition, classification,

etiology
diagnostic examination, prevention, management.

2
 b. Understanding the concept of nursing care for mothers with post-infection

partum (assessment, physical examination, nursing diagnosis,

intervention

D. Benefits of Nursing Care in Cases of Postpartum Infection

The expected benefits from obtaining the materials on
this paper is:
1. Should discuss the nursing care application with a case
Infection in Postpartum Mother.
2. As a means to enhance the knowledge that has been
obtained from the material on infections in postpartum mothers.

3. It can be used as a guideline and reference in learning.

3
 CHAPTER II

BASIC CONCEPT OF POSTPARTUM INFECTION

A. Understanding
In Latin, a certain time after giving birth
This is called puerperium, which comes from the Latin word that means baby and parous.

giving birth. The puerperium means the period after giving birth to a baby (Vivian,

2011).
The postpartum period (puerperium) begins after the placenta is born and

ends when the reproductive organs return to the state they were in before pregnancy.

This period lasts for 6-8 weeks (Saifuddin, 2006).

Postpartum infection (puerperal sepsis or fever after)
(childbirth) is a clinical infection of the genital tract that occurs within 28
the day after an abortion or delivery (Bobak, 2004).
Postpartum infection is a bacterial infection of the genital tract.
occurs after giving birth, marked by a temperature rise up to 380C or more
for 2 days in the first 10 days postpartum, excluding
The first 24 hours (Vivian, 2011).
From the above understanding, it can be concluded that postpartum infection

is all inflammation caused by the entry of germs into

In genetic tools during childbirth and postpartum, characterized by
temperature rise up to 380C or more for 2 days in the first 10 days
postpartum excluding the first 24 hours.

B. Etiology of Infection in Postpartum Mothers

This infection occurs after childbirth, when germs enter the body.
at the time of the delivery process. Among them, when the amniotic sac breaks
before and during labor takes place to become a bridge
the entry of germs into the body through the uterus. Another entry point is from
self-delivery assistants, such as non-sterile instruments used on
during the delivery process.

4
 Infection can arise from bacteria that are often found.
inside the vagina (endogenous) or as a result of exposure to pathogenic agents from

external vagina (exogenous) (Bobak, 2004).

The causes of infection include:
1. Anaerobic Streptococcus haemolyticus
Entry through exogenous means causes severe infection. This infection
usually exogenous (transmitted from other patients, unclean tools
ham, helping hands, throat infection of others.
Staphylococcus aureus
The exogenous entry, the infection is moderate, often found as
causes of infection in hospitals and in the throats of people who
it seems healthy. This germ usually causes limited infections,
although sometimes it can be a cause of common infections.

3. Escherichia Coli
Often originating from the bladder and rectum, causing infections
limited to the perineum, vulva, and endometrium. This germ is
important causes of urinary tract infections.
4. Clostridium Welchii
This bacterium is anaerobic, rarely found but very
dangerous. This infection is more frequent in criminal abortion and
childbirth assisted by a midwife outside the hospital.
(Khaidir M, 2009).

Infection in the postpartum period can occur as follows:

1. The hands of the examiner or assistant that are covered with gloves on
internal examination or surgery carries bacteria that already exist in
the vagina into the uterus. Another possibility is that the gloves
or instruments that are inserted into the birth canal are not fully
free from germs.
2. Droplet infection. Gloves or tools are contaminated with bacteria.
that comes from the nose or throat of a doctor or health worker
others. Therefore, the nose and mouth of the officers working in the room

5
 childbirth must be closed with a mask and patients with respiratory infections
breathing is prohibited from entering the delivery room.

3. In the hospital, there are too many pathogenic germs, originating from
patients with various types of infections. These germs can
carried by air currents everywhere including fabrics, tools that
cleaning ourselves, and that which is used to care for mothers during childbirth or
during the postpartum period.

4. Intercourse at the end of pregnancy is not a significant cause of infection.

unless it causes the rupture of the amniotic sac.

(Khaidir M, 2009).

Several factors in pregnancy or childbirth that can cause

postpartum infections include:
Anemia
A deficiency of red blood cells will increase the likelihood of infection.
This also occurs in mothers who are malnourished, leading to a response from blood cells.

white is less to inhibit the entry of bacteria.

2. Premature rupture of membranes

The release of amniotic fluid before the time of delivery becomes a bridge.
the entry of germs into the genital organs.

3. Trauma
Surgery, wounds or tears become entry points for germs.
pathogen, like surgery.
4. Bacterial contamination
Bacteria that are already present in the vagina or cervix can be carried to the cavity.

Rahim. In addition, the installation of instruments during the vaginal examination process or

during the delivery procedure can become one of the entry points
bacteria. Of course, if the equipment is not guaranteed to be sterilized.
5. Blood loss
Trauma that causes bleeding and manipulative actions that
related to bleeding control along with improvements

6
 wound network, is a factor that can become a pathway for entry
bear.
(Helen Varney, 2008)

C. Classification of Infections in Postpartum

1. Infection limited to the perineum, vulva, vagina, cervix, and
endometrium.
a. Vulvitis
It is an infection of the vulva. Vulvitis in postpartum mothers.
occurs at the site of the episiotomy incision or perineal wound. Edge of the wound

red and swollen, the stitches have come undone, an open wound
becomes ulcers and releases pus.
b. Vaginitis
It is an infection in the vaginal area. Vaginitis in postpartum mothers.

childbirth occurs directly on the vaginal wound or injury

perineum. Swollen and red mucous membrane surface, ulceration occurs.
and pus containing mucus that comes out of the ulcer area.
c. Servisitis
It is an infection that often occurs in the cervical area, but not
causes many symptoms. Deep and extensive cervical wounds,
and directly to the base of the ligamentum latum and can cause
infection spreading to the parametrium.
d. Endometritis
It is an infection that usually starts with a fever within 48 hours.

postpartum and fluctuating. Germs enter

endometrium (usually at the placenta insertion) in a short time
and spreads throughout the endometrium.
(Mansjoer Arif, 2002).
Mastitis
Infection in the breast. Infection occurs due to injuries on the nipple.
and the ASI dam (Mansjoer Arif, 2002).

7
3. Infections that spread through the bloodstream
Septicemia
The germs present in the uterus directly enter the bloodstream.
and cause infections. The presence of septicemia can be proven.
by cultivating germs from the blood.
b. Piemia
Infection and abscess in the affected organs preceded by
the occurrence of thrombophlebitis. From the sites of the thrombus, the embolus

small ones containing germs are released. Every time

released, the embolus enters the general blood circulation and is carried

by blood flow to other places, including the lungs, kidneys,

brain, heart, and so on cause the formation of abscesses in
those places.
c. Thrombophlebitis
The expansion of pathogen microorganism invasion that follows the bloodstream

vein along the vein and its branches.

(MA Themone, 2014).
4. Infections that spread through the lymphatic vessels
a. Parametritis
Parametritis or pelvic cellulitis is inflammation that occurs in
parametrium caused by bacterial invasion. Bacterial spread
up to the parameter occurs in more severe infections. Infection
spreading to the parametrium through lymphatic vessels or through tissues
between the two sheets of broad ligament. The parametrium can also
occurred through sialfingo-ooforitis (Sarwono, 2007).
b. Peritonitis
Inflammation of the peritoneum, which is a layer of serous membrane.
abdominal cavity (MA Themone, 2014).
5. Infection that spreads through the surface of the endometrium
a. Salpingitis: inflammatory reaction and infection in the fallopian tubes.

b. Oophoritis: infection in the ovaries (MA Themone, 2014).

8
D. Clinical Manifestations

Signs of infection according to Abrams, 1995; Rukmono, 1973; Mitchell &

Cotran, 2003 among others:
Blush
Redness or erythema is the first thing visible in the area.
that experiences inflammation. When the inflammatory reaction occurs, there is

dilation of arterioles that supply blood to the area of inflammation. Thus

more blood flows to the local microcirculation and the capillaries stretch
quickly filled with blood. This condition is called hyperemia.
or congestion, causing local redness due to acute inflammation.
2. Calor
Heat occurs simultaneously with redness from acute inflammatory reactions.
Heat is also caused by increased blood circulation. Because blood
which has a temperature of 37oC is channeled to the surface of the body that is experiencing

inflammation more than the normal area.

3. Pain
Local changes in pH or local concentrations of certain ions can
stimulating the nerve endings. The release of substances such as histamine or other substances

Other bioactives can stimulate nerves. Pain is also caused by

increased pressure due to swelling of inflamed tissue.
Tumor
Swelling is partially caused by hyperemia and mostly
caused by the delivery of fluids and cells from the bloodstream to
interstitial networks.
5. Impaired function

Based on its root word, functio laesa is a lost function.

(Dorland, 2002). Functio laesa is an inflammatory reaction that has
known. However, the mechanism is not yet understood in depth.
disruption of the inflamed network function.

9
Postpartum infections can be classified into 2 categories based on their type:
1. Infection limited to the perineum, vulva, vagina, cervix, and
endometrium.
a. The symptoms include pain and heat at the site of infection, sometimes-
sometimes painful while urinating.

b. When inflammatory fluid can come out, usually the condition is not severe, temperature

around 38 degrees Celsius and pulse below 100 per minute. If injured
the infected, covered with stitches and inflammatory fluid cannot come out,
fever can rise up to 39-40 degrees Celsius, sometimes
accompanied by shivering.

c. Endometritis :
Sometimes the lochia is held in the uterus by blood, remnants.
the placenta and the amniotic membrane referred to as lociometra and can
causing a rise in temperature.
The uterus is somewhat enlarged, tender to the touch, and soft.
(Mansjoer Arif, 2002).
2. Spread through venous pathways, lymphatic pathways, and surface
endometrium.
a. Septicemia:
From the beginning, the patient has been sick and weak.
2) Up to 3 days after delivery, the temperature rises rapidly,
usually accompanied by shivering.
3) Temperature around 39-40 degrees Celsius, general condition rapid

deteriorating, rapid pulse (140-160 beats per minute or more).

4) Patients can die within 6-7 days postpartum.
b. Piemia :
1) Shortly after giving birth, the patient already felt pain in the abdomen.
pain and temperature increased slightly.

Common infection symptoms with high fever and chills occur.

after the germs with emboli enter the general bloodstream.
The characteristic is that the temperature rises rapidly repeatedly.
accompanied by shivering followed by a drop in temperature.

10
 Gradually, symptoms of lung abscess, pneumonia, and pleuritis emerge.
(Mansjoer Arif, 2002).
3. Dissemination through the lymphatic system

a. Peritonitis :
1) In general peritonitis, there is an increase in body temperature and rapid pulse.

small intestines, bloating and pain, and there is muscular defense.

2) The face that was originally reddish became pale, with sunken eyes,
cold facial skin; there is a Hippocratic facies.
In localized pelvic peritonitis, the symptoms are not as severe.
general peritonitis.
4) Limited peritonitis: fever in the patient, lower abdomen pain but
the general condition is not good.

5) An abscess may form.

b. Parametritis (Pelvic cellulitis):
1) If a high fever persists for more than one week accompanied by pain
to the left or right and pain on internal examination, should
suspected of having pelvic cellulitis.
2) Symptoms will become increasingly clear as they progress.
On internal examination, a solid mass can be palpated and is tender.
next to the uterus.
4) In the midst of that inflamed network, an abscess can arise marked by
the initially high temperature became fluctuating accompanied by
shivering.
5) The patient appears ill, with a rapid pulse and abdominal pain (Sarwono, 2007).
4. Dissemination through the surface of the endometrium.

Salpingitis and Oophoritis:

Pressure pain on one or both sides of the abdomen.
Fever accompanied by chills.
3) Excessive secretions accompanied by pus sometimes.
(MA Themone, 2014).

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E. Pathophysiology

After stage III, the area of the former placental insertion is a

a hole with a diameter of about 4 cm, uneven surface, bumpy
because of the many veins covered by thrombus and it is a good area
for the growth of germs and the entry of pathogenic types
in the female body. The cervix often experiences injuries during childbirth,
similarly, the vulva, vagina, and perineum are entry points for germs
pathogen. The inflammatory process can be limited to those wounds or can be
spreads beyond its original wound.
The body's reaction can be a local reaction and can also occur
general reaction. In infections with a general reaction, the nerves will be involved and

metabolic at that time a light limporoticularis reaction occurred throughout the body,
in the form of proliferation of phagocytic cells and antibody-producing cells (B lymphocytes).

Then the local reaction called acute inflammation, this reaction continues
taking place during the process of network destruction by trauma. If
the causes of network destruction can be eradicated, then the remaining network that

debris will be phagocytosed and expelled by the body until it occurs

resolution and healing. When trauma is excessive, the response of phagocyte cells sometimes

excessive so that excessive debris accumulates in a cavity

forming an abscess or gathering in other body tissues forms
flegmon (widespread inflammation in connective tissue) (Sjamsuhidajat, R, 1997).

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F. Pathway

Pathogen Germ

Endogen, Eksogen, Autogen

Postpartum Infection

Localized infection High risk Infection spreads Anorexia

infection spread

Lymph Nutrient intake

Vulvitis Vaginitis Servisitis Endometritis Long-term infection and liquid

Nutrient less than

Infection Swelling Luka expands Lokia Detention Invasive actions Peritonitis Parametritis
to the base the body's needs
on the trace surface by residual blood
sayatan mucosa ligament placenta and
amniotic membrane The accumulation of pus Pain on one side
episiotomy Limitations
in the Douglas cavity uterus
movement
Emphasis Spread
network infection to Uterus
Network Abses
around parametrium endometritis Disturbance
around
swollen to grow body image
and red Swelling
Acute pain Fever 39˚C-40˚C
Nyeri
press on
Hyperthermia abdomen Acute pain

Acute pain

13
Acute pain Network
easy to let go

Open wound

Ulcer and pus

Risk of damage
network integrity

Intolerance of activity

14
G. Complications
1. Peritonitis (inflammation of the abdominal cavity lining).

2. Pelvic thrombophlebitis (blood clot in the pelvic veins), with

the risk of pulmonary embolism occurring.

3. Toxic shock due to high levels of toxins produced by bacteria in

in the blood. Toxic shock can cause severe kidney damage and
even death
(MA Themone, 2014).

H. Supporting Examination
1. White blood cell count (WBC): normal or high with a shift
differential to the left.
2. The erythrocyte sedimentation rate (ESR) and the number of red blood cells (RBC) are very

increased with the presence of infection.

3. Hemoglobin/hematocrit (Hb/Ht) decreases in conditions

anemia.
4. Culture (aerobic/anaerobic) from intrauterine or intracervical material or
drainage of wounds or gram staining in the uterus identifies organisms
cause.
5. Urinalysis and culture rule out urinary tract infection.
6. Ultrasound determines the presence of placental fragments that
localized perineal abscess.
7. Bimanual examination: determining the nature and location of pelvic pain, mass
or the formation of abscesses, as well as the presence of veins with thrombosis.

(Mitayani, 2013).

I. Prevention
1. Reducing or preventing predisposing factors such as anemia,
malnutrition and weakness and treating mother's illness.
2. Internal examinations should not be performed unless there is a necessary indication.

3. Intercourse during late pregnancy should be avoided or reduced and done

be careful as it can cause the water bag to rupture. If this happens

15
 Infection can easily enter the birth canal. Avoid prolonged labor.
and the amniotic sac broke long ago/keeping the labor from dragging on.
4. Completing childbirth with minimal trauma.
5. Performing postpartum wound care using aseptic technique.
6. Prevent excessive bleeding in case of blood loss.
must be replaced immediately with a blood transfusion.

7. All staff in the delivery room must cover their noses and mouths.
with a mask; those suffering from respiratory infections are not allowed
enter the delivery room.
8. The tools and fabrics used in childbirth must be clean.
9. Avoid repeated examinations, do it only if there are indications.
with good sterilization, especially if the amniotic fluid has broken.
(Mitayani, 2013).

J. Management
Temperature is measured at least four times a day.
2. Administer procaine penicillin antibiotic therapy 1.2-2.4 million units 1 M penicillin G

500,000 units every 6 hours or methicillin 1 g every 6 hours 1 M added

with ampicillin capsules 4x250 mg orally.
3. Observe the mother's diet; a high-calorie high-protein diet.
4. Perform a blood transfusion if necessary.
Be careful if there is an abscess, make sure the pus does not enter the cavity.
peritoneum.
(Mitayani, 2013).

16
 CHAPTER III

NURSING CARE CONCEPT FOR MOTHERS WITH

Postpartum Infection

A. Assessment
According to Ana Ratnawati (2017:203), it explains the possibility

data generated during the assessment:

1. Demographic data/client identity
Client personal data includes name, age, occupation, education, religion, ethnicity.

nation, address.
2. Health history:
a. Current health history
Clients usually complain of weakness, fever, rapid pulse, breathing.
Suffocation, body shivering, restlessness, pain in the area of the surgical wound.

Blood discharge from the birth canal that remains red

a few days postpartum or more than 2 weeks postpartum,
leucorrhea and lochia have a strong odor.
b. Medical history in the past
1) History of heart disease, hypertension, chronic kidney disease,
hemophilia, uterine fibroid, history of preeclampsia, birth canal trauma,
failure of blood vessel compression, site of placenta implantation
retention of residual placenta.

2) Family disease history, history of family members who have had/are having

suffering from hypertension, heart disease, preeclampsia, diseases

descendants, hemophilia, and infectious diseases.
c. Obstetric history
1) Menstrual history includes menarche, duration of the cycle,
the amount, the smell, and complaints during menstruation.

2) The history of marriage includes the age of marriage, marriage that

number, and pregnancy age.

17
 d. History of previous pregnancies, deliveries, and puerperium

1) The history of pregnancy includes early pregnancy, late pregnancy, and previous pregnancies.

the occurrence of abortion.

2) The history of delivery includes the age of pregnancy, method of delivery,

helper
or not, and the length of the child at birth.
3) The history of postpartum includes the condition of lochia, bleeding, adequate breast milk.

or not, the condition of the mother during postpartum, height of the fundus uteri, and

contraction.
e. Current pregnancy history
Early pregnancy: complaints during early pregnancy.

Pregnancy complaint: complaints during pregnancy, weight gain, temperature,

pulse, breathing, increased blood pressure, nutritional status due to
nausea, and other complaints.

3) The history of ANC (AnteNatal Care) includes: place of service,

the number of visits, treatments, and medications received.
f. Current childbirth history
Covering service locations, number of visits, care and
treatment that is obtained.
g. Sexual history, including previous STI history, number of partners
sexual at this time, the frequency of sexual activity in general.
h. Lifestyle, intravenous drug use or partners who
using intravenous drugs, smoking, alcohol, malnutrition, level
high stress.
3. Physical examination
a. General condition/general appearance includes level of energy, expression
the face, level of awareness, and emotional state of the client.

b. Vital signs: pulse more than 100 beats per minute, temperature 38˚C or
more.
c. Physical examination
1) Nervous system
Check for headache.

18
c. Respiratory system
Rapid/shallow breathing (severe/systemic process).
d. Digestive system
Observation of appetite, anorexia, nausea/vomiting,
constipation, diarrhea, thirst and dry mucous membranes.
Calculating bowel sounds four quadrants (bowel sounds may not
there is a case of bowel paralysis).
e. Cardiovascular system
Conjunctival anemia, tachycardia.
f. Integumentary system
Examine skin texture, edema, pain upon palpation, varicose veins.

g. Musculoskeletal system
Muscle strength test, patellar reflex, tenderness and warmth in the calves
(if there is, it indicates a positive homan sign).
h. Reproductive System
Breast
Breast shape, enlargement, symmetry, pigmentation,
color, condition of the areola and shape of the nipple, stimulation

nipple erection, swelling, lump or mass in the breast,

pressure sore, lactation/colostrum production and palpation
enlargement of axillary lymph nodes.
b) Uterus
The abdomen includes: soft to the touch, elastic texture, muscle
rectus abdominis rupture or diastasis, distension, striae.
Height of the fundus of the uterus, consistency (hard, soft, elastic), location,

uterine contractions, pain, palpation of bladder distension.

c) Vulva
Look at the structure, strain, vaginal edema, condition of the vaginal opening

(smooth, weak), the presence of hematoma, pain, and tension.

d) Perineum

19
 Condition of the wound in the perineal area and signs of infection. In the wound

episiotomy
erythema, and drainage.
e) Lochea
Color, amount, smell, blood clotting or consistency (1-3 days)
red, 4-10 days serous, >10 days white.
Anus
Hemorrhoid and thrombosis in the anus.
i. Genitourinary system
Covering whether it is fluent/not, spontaneous/not.

BN
. ursingDiagnosis
Nursing diagnosis provides an overview of the problems or
the actual health status of the client and the possibility of
It occurs (risk) of the resolution within the authority of the nurse.

Possible diagnoses include:

Hyperthermia is associated with diseases (infections).
2. Acute pain is associated with biological injury agents.
3. Nutritional imbalance less than the body's needs is related
with inadequate intake.
4. Intolerance to activity is related to weakness, infection, presence of
edema and pain, placement of infusion, anesthetic effects.
5. Body image disturbances are associated with long-term infections.
invasive actions (surgery), injections, limited movement.
6. High risk of infection spread is associated with exposure to
pathogen (childbirth trauma, birth canal, and nosocomial infection).
7. The risk of network integrity damage related to influence
infection process, scratching in the pruritic area, lesions, and abscesses.

20
C. Nursing Interventions
The nursing plan is a chain of establishment
the needs of the patient and the implementation of nursing actions. With

thus the nursing care plan is a written guideline that

accurately describing the action plan that will
done to the patient according to the needs based on
nursing diagnosis, nursing care plan for clients
postpartum according to (Dongoes, 1994: 417):
1.Dx 1: Hyperthermia is related to illness (infection).
After being treated for .... x 24 hours, it is hoped that the temperature will

client's body is within normal limits.

Criteria of results:

a. No complications

b. Normal body temperature 36˚C-37˚C

Intervention Rationale
Knowing
1. Check TTV (Temperature, Blood Pressure, Heart Rate, anddevelopment
nadi) especially temperature.
health patient and
facilitate in
administration of therapy.

2. Do a warm compress 2. Lowering hot temperature

accelerate process
evaporation of heat.

3. Collaboration : granting 3. Accelerate process

antipyretic if necessary (aspirin, healing and fast
acetaminophen. lowering fever.
Provision antibiotic
impede growth
and the process of infection.

4. Advise the client to use 4. accelerate process

blanket evaporation heat and
maintaining temperature
approaching normal.
21
 2. DX 2: Acute pain is associated with biological injury agents.
Purpose: After the nursing intervention has been carried out for .... x 24
pain can decrease or be resolved.
Outcome criteria: normal vital signs, not grimacing,
activity is not disrupted by pain, and pain scale
decrease.
Intervention Rationale
1. Determine the pain scale and 1. Knowing the indications of progress

intensity nyeri monitor or deviation from the results

blood pressure, pulse and that is expected.
breathing every 4 hours.
2. Encourage client for 2. reduce muscle tension
using technique and inhibit stimulation
relaxation and deep breath Nyeri certainly add
including distraction techniques (for oxygen intake.
mild and moderate pain.
3. Collaboration: give the medicine 4. Analgesic characteristic
analgesic as ordered. inhibiting pain receptors,
so that pain perception can
decreased or resolved.

3. DX 3: Nutritional imbalance less than the body's needs

related to inadequate intake.
Outcome criteria: body nutritional needs are met, Hb/Ht
within normal limits, body weight.

Intervention Rationale
Promote high food Protein help
protein, iron, and vitamin C improving recovery
when oral input is limited. and tissue regeneration
new, iron for
synthesis of Hb, vitamin C

22
 facilitating absorption
cell wall.
2. Increase fluid intake 2. Providing calories and
at least 2000ml per day, nutrient to meet
juice, soup and nutritional liquid. needs metabolic
replacing loss
liquid.
3. Advise the client to sleep and 3. Lowering speed
sufficient rest (adequate). metabolism process
recovery.
4. Collaborative actions: give 4. Liquid/nutrition parenteral
parental fluid/nutrition. overcoming dehydration and
replace loss
liquid/nutrition.

4.Dx 4: Activity intolerance related to weakness.

infection, presence of edema and pain, placement of infusion, effects of anesthesia.

Objective: After nursing intervention has been carried out for ...x24
The client is expected to be stable during activities.
Outcome criteria: Vital signs within normal limits, client does not
shows fatigue and lethargy, no loss of appetite,
no headaches, sleep and rest quality within limits
normal.

Intervention Rationale

Collaboration with tim Examining every aspect of the client

health lain for against the exercise therapy that

planning monitoring planned
client activity program.
Help the client choose activities 2. Activities that are too heavy
that is in accordance with the conditions and not in accordance with

23
 condition client must
worsen
Help the client to do 3. Training strength and rhythm
physical activity/exercise in a heart during activity
literature
4. Determine activity restrictions 4. Preventing usage
physical on the client excess energy
because it can cause
fatigue
5. Identify the causes of fatigue 5. Knowing the source of intake
(care, pain, treatment) client energy
6. Monitor oxygen therapy response 6. Knowing effectiveness
client O2 therapy for complaints
tightness during activity
7. Limit environmental stimuli 7. Creating environment
for client relaxation that is conducive to the client

rest

5. Dx 5: Body image disturbance associated with long-term infection

panjang, tindakan invasive (operasi SC), suntikan, keterbatasan
move.
Objective: After providing nursing care for ... x 24 hours
body image disturbances decreased.
Outcome criteria: improved self-image, appropriate self-image, and
can adapt to his health status.

Intervention Rationale
1. Assemble mutual relationship 1. Basis developing
believe nursing actions
2. Give the client a chance 2. Client needs
for to express the experience of being listened to and

feelings understood

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3. Help anxious clients 3. Neutralizing anxiety that
developing abilities it doesn't need to happen and

to assess oneself and restoring the reality of the situation,

identifying the problem fear can destroy

client adaptation
Support the client's efforts to 4. Helping improve
improving self-image acceptance here and
socialization

6D
. X6:Highriskofinfectionspreadisrelatedto
dissemination of pathogens (birth trauma, birth canal, and
hospital-acquired infection.

Objective: After nursing intervention has been performed for ... x24
After the childbirth process, the spread of infection did not occur,
achieving timely recovery, free from additional complications.
Criteria for results:

a. Vital signs within normal limits (pulse 60-80)

x/minute, temperature no more than 38˚C,
b. Dry incision
c. Lochea does not have a foul smell

d. The uterus is not soft

1–2
function laesa : normal
f. Leukocytes within normal range.

Intervention Rationale
Do it treatment Luke 1. aseptic and antiseptic techniques
with aseptic technique and minimize dan
antiseptic prevent contamination or
the correct perineum after the entry of microorganisms.
sneezing, defecation and often
change the bandage.

25
2. Observing the presence of signs2. Observation of the presence of signs-

infection in the wound area: pain, infection signs are easier

heat, redness, and loss of function. earlier intervention and
next intervention.
3. Administer antibiotics as ordered 3. Broad-spectrum antibiotics
and collaboration for can be used in
leukocyte examination prophylactic or must
addressed to on
special microorganisms.
Encourage to eat 4. Protein and vitamin C
food high protein needed for
vitamin C and iron. growth of the network and
iron rod for
the formation of hemoglobin.

5. Maintain the washing rules. 5. Washing hands helps

tight hand for staff, preventing contamination
clients and visitors. they
6. Recommend the semi-Fowler position 6. Enabling identification
beginning and action,
increasing lochia flow
and uterine drainage.

7.DX 7: Risk of network integrity damage related

with the influence of the infection process, scratching in the pruritic area, lesions,

and abscess.
Objective: After the nursing intervention has been carried out for ... x24

a good skin integrity barrier can be maintained

Criteria of results:

a. Good skin integrity can be maintained (sensation,

elasticity, temperature, hydration, pigmentation
b. There are no wounds/lesions on the skin

c. Good tissue perfusion

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 Able to protect the skin and maintain moisture
skin and natural care.

Intervention Rationale
Encourage client for Reduce probability
wearing clothes that the occurrence of wounds on the skin

loose
2. Avoid wrinkles in the area 2. Avoiding injuries to
yang lesi skin
3. Maintain skin cleanliness to ensure 3. Clean and dry skin
stay clean and dry prevent the presence of germs

that causes wounds on

skin
4. Monitor the skin for any 4. Knowing the presence of signs

redness widening irritation

5.Cleaning, monitoring 5. Preventing infections
and improve the process on the stitched wound

healing of wounds that

closed with stitching

D. Nursing Implementation
Implementation is the management and realization of a plan.
nursing that has compiled on stage planning.
(Setiadi: 2012).
Implementation is the stage of the nursing process where the nurse
providing direct and indirect nursing interventions to
client (Potter & Perry: 2009).
Implementation is an action that is in accordance with what has been
planned, includes independent actions and collaborative actions.
Independent actions are nursing actions based on analysis and
the conclusion of the nurse and not based on the instructions of other health workers.

27
 Collaborative actions are nursing actions based on
by the results of a joint decision with a doctor or other health officials.

E. Evaluation
Evaluation is an ongoing process. Evaluation
based on patient-centered goals, which were identified when
planning nursing care stages. Evaluation is a comparison.
a systemic or planned approach to patient health with the goal of
has been established, carried out in a continuous manner, with
involving patients, families, and other health personnel. (Carpenito, 1999).
Evaluation can be divided into 2 types, namely:
1. Ongoing evaluation (summative)
This type of evaluation is done in the form of filling out a record format.
development oriented towards the problems experienced by
family. The format used is the SOAP format. (Setiadi, 2008)
2. Final evaluation (formative)
This type of evaluation is carried out by comparing objectives.
that will be achieved. If there is a gap between the two,
Perhaps all stages in the nursing process need to be reviewed.
if data, issues, or plans that need to be modified are found.
(Setiadi, 2008).
The POR documentation model was introduced by Dr. Lawrence Weed.
the year 1969 with the name Problem Oriented Medical Record (POMR)
Then adopted by the world of midwifery and nursing in the form of
Problem Oriented Record (POR) was then developed into SOAP
(Subjective Information, Objective Information, Assessment and Planning).
This SOAP format is used in medical records that are oriented towards
problems (POR) that reflect the identified issues. Writing
SOAP(IER) is as follows:
S: subjective data
The issues raised by the patient and their views on the issues, if
the writing data of aphasia is 0 or X

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O: objective data
Clinical signs and facts related to nursing diagnosis
includes physiological data and information from examinations. Information comes from
family/close people
review
Analysis of subjective and objective data in determining patients. If
data may change or possibly remain the same
planning
Development of immediate/future plans for interventions/
actions to achieve optimal health status
I: intervention
Subjective data, objective data changes or not depending on the available data.
while the intervention follows the existing diagnosis
E: evaluation
It is an analysis of the patient's response to the information provided.
R: reassessment
Validation of patient data experiencing changes in patient response that will
revised for the care plan.
(Apriyani Puji Hastuti, 2011).

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 CHAPTER IV

CLOSING

A. Conclusion
Nifas or puerperium is the period of time or phase during which
reproductive organs return to a non-pregnant state. This period
takes about six weeks (Fairer, Helen, 2001:225)
Postpartum infection (puerperal sepsis or fever after childbirth)
(giving birth) is a clinical infection of the genital tract that occurs within 28
the day after an abortion or childbirth (Bobak, 2004).
Postpartum infection is a bacterial infection of the genital tract.
occurs after giving birth, marked by a temperature rise up to 38˚C
or more for 2 days in the first 10 days post-delivery, with
excluding the first 24 hours.
B. Suggestion

After reading this paper, the author hopes that the readers
especially students or health workers can understand the concepts of theory
and nursing care for postpartum mothers. So that it can
maximizing our efforts to provide health education in
perineal wound care, due to postpartum infection is commonly encountered
especially for mothers who have immune system disorders.

30
 REFERENCES

Selected Topics in Medicine

Bobak et al. 2004. Maternity nursing textbook. Jakarta EGC
Ester, Monica. 2001. Maternal/Baby Care Plan: Planning Guidelines
and documentation. Jakarta: EGC Medical Book Publisher
Invalid URL or no translatable content provided.
No translatable text provided.(accessed online March 22, 2019)
Invalid input. Please provide text for translation.
Infection (accessed online March 22, 2019)
Mitayani. 2013. Maternity Nursing Care. Jakarta: Salemba Medika
Maternal Nursing
Syamsiah Anwar. 2013. Preliminary Report and Nursing Care for Postpartum Infection

Https://id.scribd.com(accessed online March 09, 2019)

Themone, MA. 2014.Http://repository.uksw.edu/bitstream/123456789/12065/2
No translatable text provided.(accessed online March 9, 2019)
Wijayarini, Maria A. & Dr. Peter I. Anugerah. 2005. Nursing Textbook
Maternitas Edition 4. Jakarta: EGC Medical Book Publisher

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