Nursing Theory Application Of Need For Help And Unpleasant Symptoms In The Abortus Inkomplit Case Integrating Nursing Theory Need For Help and Unpleasant

Maternal deaths are mostly caused by bleeding, hypertension in pregnancy, infections, old / stuck particles and abortion. The main complaint of pregnant women who experience abortion is bleeding that occurs in the acute phase, it can threaten the safety of the mother's life. Not only cause physical impact, but can result in psychological effects of stress, anxiety, depression and grief. Gradually someone will adjust to the process of grieving. In giving nursing care with abortus incomplete used the theory of nursing need for help in the acute phase consisting of three activities of identification, ministration, validation and evaluation, while in the healing phase of post-action curettes used noses sympomps theory more focused on the symptoms experienced , which consists of three concepts namely physiological, psychosocial and situational. The results show that both models can be effectively applied to the five cases of women with incomplete abortion. growth abnormalities of the conception, placental disorders, maternal disease (syphilis, chronic pelvic inflammation and TORCH), genital tract disorders, maternal age and parity.


Introduction
The maternal mortality rate (MMR) according to the Indonesian Health Demographic Survey (IDHS) in 2012 increased from 228 to 359 maternal deaths per 100,000 live births. Most maternal deaths occur during pregnancy caused by bleeding, hypertension in pregnancy, infection, abortion (Nielson, 2014). Bleeding and complications of abortion are still the direct causes of maternal death related to pregnancy complications (The Millennium Development Goals, 2010). Pregnancy complications that occur in pregnant women in both developed and developing countries are around 15-20% of this percentage, around 9% are caused by miscarriage (who, 2010). The incidence of abortion in Indonesia is around 2 million, as many as 10-15% of them experience spontaneous abortion.
In order to improve the quality of nursing care and to develop and apply culturesensitive maternity nursing science and technology to improve community welfare. Maternity nursing specialist nurses apply nursing science that is based on evidence based, especially women's reproductive health.
Abortion is the fourth cause of maternal death, but has life-threatening complications such as perforation, bleeding, infection, and shock (WHO, 2008). In the acute phase of mothers with bleeding abortions, nurses can apply Wiedenbach's need for help theory, where the patient's physical and psychosocial needs can be met immediately. In the healing phase, namely after the curettage action, there are generally some symptoms that are felt, such as physical, psychological and situational complaints. The physiological responses that occur are pain, anemia while the psychological responses that occur are such as grieving, guilt, anger, frustration or failure, therefore support and consultation are needed to express feelings after the abortion (McCulloch, Scanion & Monchek, 2014). Symptoms that are felt after the curette action can cause discomfort so that it can interfere with or inhibit the optimal healing process, so the nurse applies the unpleasant symptoms theory.
Based on the NINR National Institute of Bnursing Research (2011) states that the quality of life of patients will be productive if they have an understanding of the symptoms they feel and the client gets the right symptom management so that it is hoped that client comfort can be fulfilled, in order to get proper symptom management in nursing care, reference is needed. or guide.

Case Overview
Case 1 Mrs. D, 22 years old, works as a housewife, has high school education, and is married. Mother was admitted to the hospital in the first pregnancy (8-9 weeks) with a history of abortion. The complaint was bleeding that had not stopped since one week ago, changing sanitary napkins three to four times a day, felt cramps in the lower abdomen. At the time of the study, the mother seemed to complain of pain and bleeding that had not stopped, BP 110/70 mmHg, pulse 88 x / minute, breathing 20 x / minute, TFU was not palpable, ultrasound examination results showed that the residual conception was still there and the patient also complained of anxiety due to was scheduled with a prior laminaria insertion. Complaints that were felt after the curettage were pain, dizziness, sadness and not knowing how to prepare for the next pregnancy. Nursing problems that arise are in the acute phase the risk of fluid imbalance, acute pain and anxiety, while in the healing phase of nursing problems that arise activity intolerance, pain, grief, increased knowledge of pregnancy preparation.

Case 2
Mrs. T, 38 years old, works as a housewife, has high school education, is married. The mother was admitted to the hospital with her fourth pregnancy and was 18 weeks pregnant. Complaints that are felt suddenly come out of blood such as liver gizzard clotted red due to frequent going up and down stairs, due to having to dry clothes, BP 110/70 mmHG, pulse 84 x / minute, breathing 20 x / minute, TFU not palpable and ultrasound results: the rest of the conception is still there and the patient also feels diabetic pain with a pain scale of five like being squeezed and the patient is anxious because of the curettage. Nursing problems that arise are in the acute phase the risk of fluid imbalance, acute pain and anxiety, while in the healing phase of nursing problems that arise, pain, grieving.
The client immediately took the curette action, the client said he was worried before the curette action. The main complaint of patients treated after curettage abortion is weakness, grieving and the patient does not know the preparation for the next pregnancy.

Case 3
Mrs. D is 22 years old working as a married housewife. The mother was admitted to the hospital with her first pregnancy with a gestational age of 8-9 weeks, a sudden complaint of blood came out suddenly and had changed sanitary napkins three to four times and felt pain on a scale of seven in the suprapubic area, USG results: the rest of the conception is still there is . On physical examination, a BP of 110/70 mmHG, pulse 84 x / minute, breathing 20 x / minute, TFU is not palpable. Patients are planned for curettage. Nursing problems that arise in the acute phase are the risk of fluid imbalance, acute pain and anxiety, while in the healing phase nursing problems that arise activity intolerance, pain, grieving, increased knowledge of post-curettage care.

Case 4
Mrs. S, 32 years old, works as a private employee, high school education, married status, mother was admitted to the hospital with a gestational age of 11-12 weeks, complaints of bleeding since one week ago and did not stop, when the BP 110/70 mmHg assessment was carried out, Nadi 84 x / minute, temperature 36 x / minute, respiration 20 x / minute, TFU was not palpable and a curettage was scheduled with laminaria insertion. The complaints that were felt before the curettage of the complaints that were felt were the risk of fluid imbalance, pain and anxiety, after the curettage action the complaints that were felt were pain, grieving, increased knowledge of post-curette care.

Literature review Complete Abortion Theory
Miscarriage is generally defined as spontaneous pregnancy loss before 24 weeks of gestation / the fetus is not ready to live outside the uterus (Nielson, 2014). There are five types of miscarriage, namely threatening abortion (imminent abortion), unavoidable abortion (incipient abortion) because the cervix has opened, miscarriage that occurs with part of the conception already out and can be seen divagina (incomplete abortion) and delayed conception in the uterus. , the results of the conception are still there but have not developed and the heart rate is no longer active but the cervix is still closed (missed abortion) and all the products of conception have been removed, significant pain and bleeding should stop (complete abortion). Some of the causes of abortion are maternal age, parity, pregnancy interval of less than two years (Prawaihardjo, 2009). In general, signs and symptoms of incomplete abortion are vaginal bleeding, abdominal cramps, cervical dilatation with visible cervical tissue (Smith, 2018).
According to Yang-Kuah (2013), the most common complaints are bleeding and pain. The medical management of incomplete abortion that is often used is mifeprostol (antiprogestin) which has the function of triggering uterine contractions and methotrexate which is an antimetabolite that interferes with embryonic development, can be used in pregnancies of less than 8 weeks while misoprostol (protaglandin) can be used at 23 weeks of gestation. so that after consumption it is advisable to immediately remove the results of the conception, otherwise surgical techniques can be performed. Surgical techniques that can be performed are curettage or vacuum, which was previously dilated (dilated) through an osmotic dilator (laminaria).

Nursing Theory Underlying Nursing Care
Loss is an acute condition that can be experienced by every individual when they part with something that previously existed, either partially or completely (Sari, 2015). Grieving is an emotional reaction after the death of a loved one, divorce, loss of a body part or function, loss of self-esteem, it is a normal reaction. There is no limit to the time it takes a person to adjust to loss. The grieving process for a person can be reduced gradually with the support of family, friends and community, while grieving that is long enough or causes a serious condition requires medical help (Moore, 2011). According to Dr. Kubler Ross. The stages of grieving are denial, denial, anger, depression, anxiety, guilt, bargaining (Belon, et. Al. 2014). The factors that affect the intensity and duration of the grieving response depend on the perception of loss, age and religious beliefs, changes in loss brought into life, personal ability to cope with loss and the existing support system (Bobak, 2005).

Need for Help Theory
This theory is used in the case of incomplete abortion in the acute phase, where there is excessive bleeding which is at risk of shock, so that the role of maternity specialist nurses is needed in this emergency condition, by applying the nursing theory "Need for Help Wiedenbach". This theory is defined as an activity "Here. and now "given by nurses to patients to solve their health problems and be patient-centered. Nursing theory of need for help according to Wiedenbach is a series of activities carried out by maternity health professionals aimed at making patients feel comfortable so that they have the strength and ability to use positive coping in solving their problems (Alligood & Tomey, 2006). This activity basically has three stages, namely identification, administration and coordination and validation.

Unpleasant Symptom Theory
The unpleasant symptoms theory is a theory developed by Lenz, Pugh, Miligan and Suppe starting in 1995. The assumption in this theory is that proper management of a symptom will contribute to resolving symptoms. the other, which has three main components, namely symptoms, influencing factors (physiological, psychological and situational factors) and the output or result of a symptom experienced (performance).
According to Lenz & Pugh (2008), symptoms have four dimensions that need to be studied, namely intensity, distress, duration and quality. The intensity dimension shows the degree of symptom in quantity, the strength of a symptom. For example the use of a pain scale during uterine contractions. The distress dimension shows the affective aspect of the symptoms experienced. Several individuals who experience the same intensity of a symptom may show different distress. The duration dimension shows the length of the symptoms felt by the individual. The last dimension is the quality that describes individual experiences.
The factors affecting unpleasant symptoms are physiological, psychological and situational. Physiological factors include inadequate hydration status due to excessive bleeding. Examples of physiological factors that will cause unpleasant symptoms are the side effects caused by curettage.
Psychological factors consist of affective and cognitive variables. Affective variables that can be observed include mood, anxiety, depression, feelings of anger and feelings of fear. Cognitive variables include the level of individual knowledge of the symptoms caused by curettage and the individual's ability to develop coping.
Situational factors include the individual environment, both social and physical.
Another situational factor is previous experience, namely the ability to access health services. Through the unpleasant symptoms theory, it is hoped that a better understanding of the symptoms and symptom collection felt by the client, so that through proper symptom management, it is hoped that the client's comfort can be fulfilled.
The goals set out in nursing interventions can refer to the improvement of the symptoms themselves, changes in influencing factors and the client's final appearance. In increasing the need for comfort, the ultimate goal of the intervention plan is to provide the client with optimal comfort, even though the client is still in the process of pain and powdering. Everyone has different responses in dealing with problems so that the preparation of interventions can be tailored to the client's conditions.
In the unpleasant symptoms theory, the evaluation focuses on the appearance of the unpleasant symptoms experienced by the client. In addition, the unpleasant symtomps theory suggests that the nurse needs to evaluate the client's final appearance to determine the quality of whether the client's life is generally compromised or not. This evaluation can be carried out periodically in accordance with the development of the client's condition, with the aim of following up on nursing intervention and implementation.

Result
Mrs. E. is 27 years old working as a married housewife. The mother was admitted to the hospital with a second pregnancy with a gestational age of 12-13 weeks, the complaint was felt suddenly a lot of blood came out clotted like ati and a day changing sanitary napkins three to four times and the patient said that since she was pregnant she still often breastfed her first child so that she often had contractions and complaints the other is cramps in the lower abdomen with a pain scale of seven like being squeezed in the lower abdominal area, at the time of the study the mother appeared to grimace in pain while holding her stomach BP 110/70 mmHg, pulse 88x / minute, breaths 20 x / minute, TFU is not palpable, and there is still a lot of blood coming out if it moves, the client immediately takes a curette, the client says he is worried before the curette action. The main complaints of patients being treated after curettage abortion are weakness, grieving and the patient does not know the postcurette care.
At the ministration stage there are 3 nursing diagnoses that can be enforced on Mrs. E, in the acute phase, namely the first nursing diagnosis, namely the risk of fluid imbalance associated with excessive bleeding associated with blood loss. The second nursing diagnosis is acute pain associated with an increase in uterine contractions. The third nursing diagnosis is anxiety related to the crisis situation and lack of knowledge about curettage procedures.
Nursing interventions given in the acute phase are meeting fluid needs by collaborating with intravenous fluids, observing vital signs and signs of hypovolemic shock including blood pressure, pulse temperature and respiration, and level of awareness, observing capillary refills, teaching relaxation techniques. deep breaths to reduce pain and collaborate giving analgesics, then prepare for curettage, overcome anxiety by providing support and health education to patients and families.
Nursing interventions given in the acute phase are meeting fluid needs by collaborating with intravenous fluids, observing vital signs and signs of hypovolemic shock including blood pressure, pulse temperature and respiration, and level of awareness, observing capillary refills, teaching relaxation techniques. deep breaths to reduce pain and collaborate giving analgesics, then prepare for curettage, overcome anxiety by providing support and health education to patients and families.
In the validation stage, an evaluation of the fluid balance was carried out, it was found that there were no signs of shock with the results of blood pressure 110/70 mmHg, pulse 88x / minute, breathing 20 x / minute, temperature 36, 7 0C, the patient's client and Jurnal Keperawatan Cikini e-ISSN 2686-1984Vol. 2, No. 1, January 2021 Ira Sukyati dkk (Nursing Theory Application Of Need For Help And Unpleasant Symptoms) family were not feeling anxious and ready for curettage. Patients can deal with pain with the help of their family and have been curetted.
Nursing provision was continued in the recovery phase using the unpleasant symptoms theory. The assessment carried out in this phase includes physiological, psychological and situational aspects.
In the post-curettage recovery phase, three nursing diagnoses were obtained, namely activity intolerance related to weakness due to the effects of anesthesia. Grieving is related to the loss of her pregnancy, the readiness to increase the knowledge of the patient and family in the next pregnancy care.
In the intervention and implementation stage of the nursing diagnosis of activity intolerance related to the effects of anesthesia, mobilization has been carried out gradually, providing information on the importance of mobilizing as early as possible in stages, helping patients meet daily needs, observing vital signs, helping patients to mobilize, monitor the increase in patient mobility.
Grieving is associated with the loss of pregnancy. Nursing implementation is carried out by fostering a trusting relationship with the patient, inviting clients to discuss the patient's state of mind, feelings, physical, social and spiritual conditions before and after experiencing loss, effective ways of coping with grief such as verbal, physical, social or self-help. groups, a spiritual way by informing the importance of prayer and other religious activities that can be carried out by patients, identifying their potential and resources, providing assistance to patients, motivating husbands or families to always be there, reminding clients that the events they experienced were a disaster and not only. himself who experienced.
The next nursing implementation is providing information to clients and families on post-curettage care such as routine examinations, the importance of consuming nutrition with balanced nutrition after curettage and preparation for the next pregnancy, and the importance of postcurette family planning, observing signs of post-curettage the importance of paying attention to personal hygiene..

Discussion
In five managed cases, the main reason for seeking help was due to bleeding starting with a large amount of blood as much as 3 people and a small amount of blood as much as two people. Other symptoms reported, namely pain / cramps in the abdomen were also reported in three patients who were managed while two patients did not experience pain / cramps in the abdomen, this is in accordance with the results of a study by Yassae et.al (2008) on 60 pregnant women with abortion, the results were all. Respondents at the initial stage experienced bleeding with a classification of 16.7%, namely 5 people experienced bleeding in a considerable amount, while the remaining 83.3%, namely 25 people only experienced bleeding in a small amount, while the experience of pain in abortion patients was based on research. 9 people with a percentage of 30% experienced pain during an abortion and 21 people with a percentage of 70% experienced no pain. Pregnant women who experience bleeding are around 25% with an incidence of 80% experiencing abortion occurring in the first trimester (Salhi, and Nagrani, 2018).
In five cases, it was managed to determine the source of bleeding, the diagnostic tests were carried out, namely in two cases, a transvaginal ultrasound examination was carried out because the gestational age was less than eight weeks with a small amount of bleeding and lasted one week ago with the aim of ensuring the health of the fetus and the result was that both fetuses were unable. maintained further that the patient was planned to be hospitalized for laminaria insertion and curettage and three other cases were subjected to internal examinations due to the bleeding that occurs suddenly in a considerable amount, and internal examination is carried out to determine whether there is cervical opening and the source of the bleeding, so that further action can be determined and the result is an opening of about two to three cm and a curettage is planned immediately. This is in accordance with the theory put forward by Yang-kuah (2013), in the case of incomplete abortion, surgical techniques to prevent prolonged bleeding and to remove the remaining conception are performed by curettage which was previously dilated (dilated) through osmotic dilators (laminaria).
Based on the theory put forward by Salhi and Nagrani (2018), several risk factors for abortion, namely increasing maternal age, increased parity, previous history of miscarriage, uncontrolled diabetes mellitus and thyroid disease, obesity, maternal stress and a history of vaginal bleeding. In five cases, the risk factor for bleeding was an increase in maternal age, in the case there was one patient who was 38 years old, while the others had an age range of 20 to 35 years, other risk factors were one patient who had a history of abortion and one other patient because a pregnancy interval of less than two years and one other case due to fatigue, because the mother worked as a private employee. This is consistent with a study conducted by Patriani (2013), namely women who are pregnant with a pregnancy interval of less than two years are at risk of twice as having an incomplete abortion, likewise mothers who work have four times the risk of incomplete abortion compared to those who do not work. and one other case the cause is not yet known, because it is the first time you are pregnant at eight weeks of gestation, this is in accordance with the theory put forward by Simpson (2017) that most of the complications that occur in early pregnancy are caused by the early formation of the placenta. This was also stated by Prawihardjo (2006), some of the causes of abortion, namely growth abnormalities of the conception, placental disorders, maternal disease (syphilis, chronic pelvic inflammation and TORCH), genital tract disorders, maternal age and parity.
Pregnant women who experience an abortion are not only physically disturbed but are at risk of causing psychological problems, the impact of which will be carried over to subsequent pregnancies, namely psychological stresses such as stress, depression, anxiety and grief. Grieving is an emotional reaction after the death of a loved one, divorce, loss of a body part or function, loss of self-esteem, it is a normal reaction, then gradually adjusts to the grieving process, then is able to make positive plans. There is no limit to the time it takes for someone to adjust to losses. The grieving process for a person can be reduced gradually with the support of family, friends and community, while grieving that is long enough or causes a serious condition requires medical help (Moore, 2011).
According to Belon et. al (2014) the grieving experiences of patients vary significantly, for example the existence of different cultures and individuals and different adverse experiences. Meanwhile, according to Bobak (2005) that individuals have a unique way of reacting to this loss based on personal experience, cultural expectations and spiritual beliefs. The factors that influence the intensity and duration of the grieving response depend on the perception of loss, age and religious beliefs, changes in loss brought into life, personal ability to cope with loss and the existing support system. The psychological consequences that occur for each woman vary with families who have different cultures (Seibel and Graves, 1980). In principle, management in all cases is to stop bleeding and prevent hypovolemic shock. This can be done independently by the nurse by observing vital signs including blood pressure, pulse, temperature and respiration. According to Cuningham (2013), the signs of hypovolemic shock caused by bleeding are decreased blood pressure and increased pulse frequency.
Collaborative actions that have been taken are giving intravenous fluids, conducting blood tests of the patient's hemoglobin levels. In all five managed cases, all RL was attached with 20 tts / minute and blood tests were carried out with normal hemoglobin results.
Nursing problems in the psychological aspects experienced in the acute phase, namely anxiety related to curettage. In the healing phase, the physiological problems experienced are grief, guilt, anger, frustration and failure, so that after the curettage action, support and motivation are needed to the patient to tell the feelings he feels (McCulloch, Scanion & Monchek, 2014). In addition, the psychological impact will affect subsequent pregnancies (Bergener, et al. 2008). So it takes the role of specialist nurses as professionals related to physical and psychological preparation in providing information about increasing maternal knowledge about post-curricular care, as well as explaining the importance of family participation. especially the husband as the closest person to provide motivation and full attention to patients.

Conclusion
Patients with incomplete abortion had almost the same complaints and signs and symptoms that all had bleeding. By using the application of the theory of need-for-help nursing which is used in the acute phase, appropriate measures are obtained that aim to prevent complications such as shock and thus prevent the increase in maternal mortality due to bleeding.
In the recovery phase, the focus of the unpleasant symptoms theory is on the symptoms felt by the patient, both physiological, psychological and situational. By using the nursing theory of need for help and unpleasant symptoms in cases of incomplete abortion, the authors have a different experience, namely that nursing care is more comprehensive given to patients, this is proven by patients and families who look calmer and more comfortable and enthusiastic when included in the implementation. Nursing theory is very important in providing nursing care, so that quality and effective nursing care can be provided, and in the end, optimally solve the patient's health problems, both physically and psychologically.