Nursing Care for Mrs. W P3A0 with Post Sectio Caesarea Indication Severe Pre-Eclampsia in the Rose Chamber: A Case Study

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INTRODUCTION
Severe pre-eclampsia is one of the causes of complications in pregnancy, which is characterized by an increase in blood pressure > 160/110 mmHg, so delivery must be carried out by cesarean section (SC), and even death can occur if not treated immediately (Garrido-Gomez et al., 2017;Kumar et al., 2014;Qiu et al., 2021;Tolcher & Aagaard, 2024).According to the World Health Organization (WHO) (2019), the incidence rate of pre-eclampsia in the world is around 0.51--38.4%;women living in developing countries have a higher risk of developing pre-eclampsia.Pre-eclampsia has an impact on pregnant women, mothers giving birth, and also causes postpartum problems due to dysfunction of various organs such as the heart, kidneys, liver and brain (Retnowati, 2021).Maternal death is caused by disturbances during pregnancy or during childbirth.In Indonesia, the maternal mortality rate (MMR) reached 305 per 100,000 live births in 2019.Pre-eclampsia is the second highest cause of maternal mortality after hemorrhage, which is 26.47% (76.97 per 100,000 live births) (Ministry of Health of the Republic of Indonesia, 2019).
There are several risk factors that affect the occurrence of pre-eclampsia, such as age (> 35 years), having a history of hypertension, first pregnancy, and obesity.Other factors that can affect the risk of pre-eclampsia are diabetes mellitus, multiple pregnancies, previous history of pre-eclampsia and a family history of pre-eclampsia (Mohanty et al., 2019).The management of pre-eclampsia depends on the mother's gestational age.Actions carried out by performing SC operative actions or by normal childbirth (Tiruneh et al., 2024).One of the indications of SC is a severe pre-eclampsia disease, which requires SC delivery for several reasons, including accelerated birth due to seizures in the mother.
SC is a medical procedure that is necessary when normal delivery is not possible due to maternal health problems or fetal conditions.The SC procedure involves surgery to open the abdominal wall and uterine wall to deliver the fetus from within the uterus (Lupu et al., 2023;Mylonas & Friese, 2015;Ningsih & Rahmadhani, 2022;Zuhana et al., 2020).According to Basic Health Research (2018), births with the SC delivery method in Indonesia are around 17.6% of all births.SC section is associated with short-term and longterm risks that continue for many years after delivery and affect the health of the mother, baby and future pregnancies.SC surgery is also often associated with pain in the abdominal wall and uterus after surgery, which can delay recovery to return to daily activities, have an impact on the mother's psychological well-being, and can make breastfeeding difficult (Haarman et al., 2021).
Despite the recognition of nurses' roles in providing post-cesarean care, there is a lack of detailed studies focusing specifically on the unique challenges and strategies employed by nurses in managing patients with severe pre-eclampsia.Most existing research broadly addresses post-operative care without delving into condition-specific protocols and the impact of specialized nursing interventions.This study aims to fill this gap by exploring the specific roles, practices, and challenges faced by nurses in handling post-cesarean patients with severe pre-eclampsia.The novelty of this research lies in its targeted examination of the critical role of nursing care in improving patient outcomes in this high-risk group, providing insights that could inform future clinical practices and policies.
Based on these data and information, the author is interested in conducting a case study by providing nursing care to severe pre-eclampsia patients in meeting patient needs.In accordance with the background that has been stated, the objectives of this study include being able to explain the basic concept of nursing care in Mrs. W P3A0 with post-SC indications of severe pre-eclampsia in the rose room.This research contributes to the understanding and improvement of nursing care practices for post-cesarean section patients with severe pre-eclampsia, aiming to enhance patient outcomes and provide a framework for similar cases in clinical settings.

RESEARCH METHODS
This study uses a case study approach.A case study is a study conducted by conducting an in-depth study of a specific case whose conclusions are limited or applicable to a specific case only (Bass et al., 2018;MARIOTTO et al., 2014;Rashid et al., 2019;Welch et al., 2020).This case study was conducted with the aim of exploring nursing care in patients with post-SC section indications of severe pre-eclampsia.The collection of this case was carried out in the rose room of Waled Cirebon Hospital on December 30 th , 2023.The data collection carried out by the researcher in managing this case study includes observation, interviews, and documentation studies.Data analysis is carried out from the time the researcher is in the research field, during the data collection, until the data is collected.Then by observation by the researcher, conducting interviews with patients, and documentation studies that produce data for the researcher to subsequently collect.The data collected is in the form of objective data and subjective data, then the researcher prepares a nursing care plan and implements and evaluates the nursing care that has been provided to patients using summative and formative evaluations.

RESULTS AND DISCUSSION
The results of the assessment were obtained by a patient named Mrs.W, 38 years old, with a medical diagnosis of P3A0 with PEB + history of SC 17 years ago + MOW.The date of admission to the hospital is December 29 th , 2023, and the date of the assessment is December 30 th , 2023.The main complaint during the assessment was post-SC pain.Provocation (P): the patient said pain, the pain arose when doing movements and the pain disappeared when resting.Quality (Q): the patient said the pain was like being stabbed.Radiation (R): the patient said pain in the abdomen post-SC.Severity (S): the patient said pain on a scale of 5 (0--10).Time (T): The patient says the pain disappears.Menstrual history: menarche age 12 years, length of menstruation for one week, cycle 28 days, HPHT March 23 rd , 2023, estimated delivery December 30 th , 2023.The type of contraception used before pregnancy is three-month injectable birth control for one year.Current delivery history: delivery date December 30 th , 2023, at 10.45 WIB, type of SC delivery, phase I: 8 hours opening 1--10, phase II: 1 hour of baby delivery, phase III: 5 minutes of placental discharge, phase IV: 2 hours of post-SC observation, amount of bleeding 300 ml, gender of a baby boy weighing 3.4 kg and height 50 cm.Physical examination results: moderate condition of the patient, basic composment, TD 130/80 mmHg, pulse 101 x/min, respiration 20 x/min, temperature 36.8 °C, reproductive system: nipple formed, mama's areola is black, no lump on the mamae, no milk output, no varicose veins, there is lochia rubra, there is tenderness in the abdomen post-SC.Laboratory examination results: Hemoglobin 11.9 gr%, leukocytes 10.3/mm³.The patient was given an infusion of RL 20 tpm, ketorolac 3x1 gr, metronidazole 2x500 mg, ambacim 2x1 gr.
The nursing diagnosis raised by Mrs. W is acute pain, B.D post-SC wounds, ineffective breastfeeding, B.D inadequate breast milk supply, impaired physical mobility B.D pain.
Nursing interventions carried out to overcome acute pain problems are the identification of general conditions, awareness and vital signs, identification of location, characteristics, quality, duration, frequency, intensity of pain, identification of pain scale, providing non-pharmacological techniques to reduce pain, teach non-pharmacological techniques to reduce pain, a collaboration of analgetic administration.Nursing interventions carried out to overcome ineffective breastfeeding problems are identifying breastfeeding goals or desires, supporting mothers to increase confidence in breastfeeding, providing breastfeeding counseling, explaining the benefits of breastfeeding and attachment correctly, teaching antepartum breast care by compressing with cotton swabs that have been given coconut oil, teaching postpartum breast care (breast care).Nursing interventions carried out to overcome the problem of physical mobility disorders are the identification of physical pain or complaints, identification of physical tolerance for movement, involvement of families to help patients in improving movement, and teaching simple mobilization that must be done.
Evaluation of the implementation of nursing for 3x24 hours.There were three nursing diagnoses that were resolved, namely acute pain, ineffective breastfeeding, and physical mobility disorders, with the results of the evaluation showing that the patient revealed that the pain was reduced on a scale of 3, breast milk had started to be produced and expressed, and mobilization had been smooth.
The patient said pain in the wound of the post-SC.This is in accordance with the theory that giving birth by SC section can cause pain because the tissue that undergoes an incision can cause a break in the continuity of the nerve endings that are removed during surgery or the occurrence of ischemic in the tissue due to the impaired blood flow to one part of the tissue (Tirtawati et al., 2020).
The administration of analgesics can lower or control pain after the SC section.The analgetic will immediately reach the center of pain, giving rise to more effective relief.During the evaluation on the second day after the intervention, the patient said that the pain had begun to decrease, but moving was still painful; on the third day, the pain had reduced, and the patient was able to sit down, even when changing places, the pain was not so felt.
The implementation carried out is to carry out non-pharmacological techniques to facilitate breast milk with breast massage.In line with the research of Sandriani et al. (2023), to overcome breast milk problems in mothers giving birth, perform breast massage, which functions to provide comfort to the mother, reduce breast swelling, stimulate the release of the hormone oxytocin and maintain breast milk production when the baby and mother are sick.
In addition, breast care also has other purposes, namely preventing breast milk blockages, maintaining the flexibility of the nipples to prevent irritation or abrasions on the mother's nipples, and maintaining hygiene (Aeni et al., 2022).This theory is in accordance with the research of Lestari (2019) that after breast care interventions for three consecutive with a frequency of 2 times per day for 30 minutes, it has proven to be effective in increasing milk production quantitatively.Evaluation on the third day after the intervention, the patient said that the body felt relaxed and comfortable during and after the breast care massage.The patient said that he had done breast care, such as cleaning the nipple with a cotton swab moistened with oil or baby oil; the breast milk had come out but only a little.
Physical mobility disorder intervention based on SIKI (2018), namely mobility support.According to research by Rottie & Saragih (2019), one of the mobilization supports carried out by nurses and families for physical mobility disorders is early ambulation, which is a movement that is carried out as early as possible in bed, namely on the first day after SC surgery by tilting right and left accompanied by nurses and families by training body parts to stretch which can help heal wounds in post-SC mothers.
The importance of early mobilization because it can accelerate the healing process of post-SC mothers so that patients can return to normal activities.If it is too late to mobilize early, it will slow down to worsen during the post-SC recovery period (Rottie & Saragih, 2019).The evaluation on the third day after the early ambulation intervention was that the patient said that he was able to move, such as sitting, walking and doing other activities after being accompanied by early ambulation and because the post-SC pain had decreased.

CONCLUSION
Based on the results of the study using the maternity case study method in Mrs. W patients with severe pre-eclampsia in the rose room of Waled Cirebon Hospital, it was concluded that nursing problems in patients were acute pain, ineffective breastfeeding, and impaired physical mobility.The implementation of nursing actions in this case was carried out in accordance with data analysis, established nursing diagnoses, and nursing interventions that had been made in accordance with the needs of severe pre-eclampsia patients.After the implementation of nursing for Mrs. W with severe pre-eclampsia for 3 x 24 hours, the final result of the nursing process is an evaluation of the nursing care provided.In the evaluation, there were three nursing diagnoses that had been resolved according to the plan and the intervention was stopped.
Based on the results of the study using the maternity case study method in Mrs. W, a patient with severe pre-eclampsia in the rose room of Waled Cirebon Hospital, it was concluded that nursing problems in patients included acute pain, ineffective breastfeeding, and impaired physical mobility.The implementation of nursing actions in this case was carried out in accordance with data analysis, established nursing diagnoses, and nursing interventions tailored to the needs of severe pre-eclampsia patients.After the implementation of nursing care for Mrs. W with severe pre-eclampsia for 3 x 24 hours, the final result of the nursing process was an evaluation of the nursing care provided.The evaluation showed that three nursing diagnoses had been resolved according to the plan, and the intervention was stopped.

Future Research Directions Long-term Outcomes
Investigate the long-term outcomes of patients with severe pre-eclampsia who receive specific nursing interventions.This could provide valuable insights into the sustained effectiveness of nursing care.

Comparative Studies
Conduct comparative studies between different nursing intervention strategies for severe pre-eclampsia patients to determine the most effective approaches in various settings.

Patient Education
Examine the impact of comprehensive patient education programs on the management of severe pre-eclampsia, particularly focusing on breastfeeding success and physical mobility post-delivery.

Technological Integration
Assess the role of technology and digital health tools in improving nursing care and patient outcomes in cases of severe pre-eclampsia.

Interdisciplinary Collaboration
Explore the benefits of interdisciplinary collaboration between nurses, obstetricians, and other healthcare professionals in managing severe pre-eclampsia to enhance patient care.
By addressing these areas, future research can contribute to a deeper understanding of effective nursing interventions for severe pre-eclampsia and improve overall patient care outcomes.