ASUHAN KEPERAWATAN D I S U S U N OLEH ANNISHA RAHMANI P3.73.20.1.10.

090
PROGRAM UNGGULAN BERTARAF INTERNASIONAL JURUSAN KEPERAWATAN POLTEKKES KESEHATAN JAKARTA III

ASSESSMENT
FOCUS DATA
a. Subjective Data The client said that the client feels so tired The client said that 2 months ago she gets hyperglycemia The client said that her blood glucose is 154 mg/dl The client said that the client get medicine from public health center The client said that the client did not know about her diseases/high blood glucose The client also said that she doesnt know the etiology from high blood glucose The client said that her medicine was empty The client said that she feels better than before and never control in public health service The client said that her legs sometimes feels distention The client said that her legs feels tingling The client said that her legs sometimes feel numbness The client said that the client doesnt know the asam urat The client said that the client doesnt know the reason or etiology from asam urat The client said that when the pain comes the client only massage with their oil.

b. Objective Data The client looks so nice The client 47 years old The client looks tired The client looks sweaty The client can not answer the question about her disease (high blood glucose/diabetes mellitus and uric acid The client look hold her legs which one that her feels so sick The client look massage her legs Based on the result of laboratory the blood glucose of client : 154 mg/dl Body Height is : 157 cm Body Weight : 55 kg BMI = BB/ (TB)2

= 55/(2,46) = 22,35 IBW = (TB-100)-10% (TB-100) = (157-100)-10% (157-100) = 57-5,7 = 51,3 kg

Uric acidvalue is 9,6 mg/dl Blood Pressure 110/ 70 mmHg Respiratory Rate 24x/menit Pulse 80x/menit Temperature 36,6o celcius

ANALISA DATA NO
1. -

DATA FOKUS
Data Subjektif : The client said that feels tired

MASALAH
Knowledge about her disease her

ETIOLOGY
disease in Mr. M

deficit Lack of information about

The client said that 2 months ago the diabetes

mellitus

or especially Mrs. J

blood glucose of the client was hight blood glucose in increase. Mr. M family

The client said the blood glucose of especially Mrs. J the client is 154 mg/dl

The client said that the client gets drug from the public heart cervice

The client said that the client said that the client does not know about her disease (high blood glucose or

diabetes mellitus) The client does not know what is the reason of her disease (high blood glucose or diabetes mellitus) The client also didnt know about the reason of high blood glucose The client said that she never control at public health cervices because she feels get better.

Objective Data : General condition of client looks good The client 47 years old The client looks tired The client looks sweaty The client doesnt answer the

question about her disease

Based on the laboratory diagnostic result that the value blood glucose of the client is 154mg/dl since 2 months ago

Body height = 157 cm Body weight before illness = 50,5 kg Body weight after illness = 55 kg BMI = BB/ (TB)2 = 55/(2,46) = 22,35

IBW = (TB-100)-10% (TB-100) = (157-100)-10% (157-100) = 57-5,7 = 51,3 kg

Blood Pressure 110/ 70 mmHg Respiratory rate 24x/menit Pulse 80x/menit Temperature 36,6o celcius

2.

Subjective Data : -

Knowledge

deficit Lack of information about

The client said that her legs feels has about uric acid disease uric acid disease in Mr. M cramps in Mr. M family family especially Mrs. J

The client said that her legs feels so especially Mrs. J sick

The client said that her legs feels tingling

The client said that her legs feels numbness The client said that she doesnt has uric acid The client said that the client didnt know about uric acid The client said that doesnt know

about the causes of uric acid The client said that when the pain comes the client only give the massage oil (minyak kayu putih, balsam, minyak kelapa atau minyak urut)

Objective Data : General condition of client looks good The client 47 years old The client looks hold her legs which one she feels pain The client also looks massage her legs which one she feels pain The client does not know about uric acid The client also does not know the causes about uric acid Body height = 157 cm Body weight before illness = 50,5 kg Body weight after illness = 55 kg Uric acid value = 9,6 % Blood Pressure 110/ 70 mmHg Respiratory rate 24x/menit Pulse 80x/menit Temperature 36,6o celcius

FORM THE PRIORITY OF NURSING DIAGNOSE IN FAMILY Name : Mrs. J NO 1. CRITERIA The characteristic of the problem Actual Risk =3 =2 Age : 47 years old SCORE Problem : Diabetes Mellitus JUSTIFICATION

PROFOUND 1

3/3 x 1 = The characteristic of health problem 1 is actual because when the student collage doing assessment her blood glucose is high than before 154 mg/dl (normally = 110-140 mg/dl) x2= 1 Based on Mrs. J problems that looking difficult for changing because the clients family said that it difficult if change the eat pattern.

Potential =1 2. Possible the problem 2 for changing : Easy = 2 Partial = 1 Difficult = 0 3. Potential prevent the problem Height = 3 Middle = 2 Lower = 1 1

2/3 x 1 = The potential for disease prevention 2/3 because the problem is being

experienced by Mrs. A client is caused by eating poorly controlled. Clients say that the client is very difficult to control her diet.

4.

The priority Perceived problems should be handled = 2 The problem is felt not need to be handled = 1 The problem is not perceived = 0 TOTAL SCORE

0/2 x 1 =0

Related to the priority of health problem, Mrs. J and her family has perception that when the medicine therapy was finished, Mrs. J feel better so she didnt need to control in public health care.

2 2/3

FORMAT THE PRIORITY OF NURSING DIAGNOSE IN FAMILY Name : Mrs. J NO 1. CRITERIA The characteristic of the problem Actual Risk =3 =2 Age : 47 years old SCORE 3/3 x 1 = 1 The Problem : Uric acid JUSTIFICATION characteristic of health

PROFOUND 1

problem is actual because when I assess her health problem, she feels pain on her joint. Based on the result of uric acid diagnostic test, the clients score is 9,6 mg/dl while the normal value of uric acid for women is 2,6 6 mg/dl. Mrs. Js problem is said to be changed partly because the family does not know how to solve the health problems that occur.

Potential =1

2.

Possible the problem for changing : Easy = 2 Partial = 1 Difficult = 0

x2=1

Clients just massaging her legs. 1 1/3 x 1 = 1/3 Potential prevention of health problems say low because clients like green vegetables and hard to change the health problems

3.

Potential prevent the problem Height = 3 Middle = 2 Lower = 1

experienced. 1 0/2 x 1 =0 Related to the priority of health problem, Mrs. J and her family think that is not important to go to public health service because clients and his own family

4.

The priority Perceived problems should be handled = 2 The problem is felt not need to be handled = 1 The problem is not perceived = 0 TOTAL SCORE

thought that pain is reasonable because exhaustion.

2 1/3

PLANNING OF NURSING CARE with Mr. M ESPECIALLY Mrs. J NO 1. NURSING DX.

Lack of knowledge

GOAL GENERAL
After doing health promotion, the -

NURSING SPECIFIC
Mention understanding the definition of

EVALUATION CRITERIA STANDAR

the definition of

INTERVENTION
the client and her family 2. Assess the client identity condition 3. Assess the physical examination health and

the 1. Make trash with Respond verbal 1. Client can mention

about diabetes mellitus/ high blood glucose in Mr. Ms family

client and her family are can about mellitus. expected that -

diabetes mellitus.

diabetes mellitus Mention etiology the of

especially Mrs. J.

understand diabetes

2. Client can mention the etiology of

diabetes mellitus Mention sign and synmptom

diabetes mellitus

of 4. Give promotion/ education the mellitus

3. The

client

can

diabetes mellitus Mention complication the of

mention about diabetes

the sign

and synmptoms of diabetes mellitus

diabetes mellitus Mention preventive the of

4. The

client

can the of

mention complication

diabetes mellitus d

diabetes mellitus.

Mention traditional treatment of 5. The client can the of

mention prevention diabetes mellitus

diabetes mellitus.

6. The

client

can the

mention

traditional treatment of diabetes mellitus.

2.

Lack

of

knowledge After

doing health

Mention

the 1. Make trash with Respond verbal 1. The the client and her family the 2. Assess the client identity condition. and

client

can the

about uric acid in Mr. promotion, the client Ms family especially and her family will be Mrs. J. expected for -

definition of uric acid Mention

mentiom

definition about uric acid 2. The client can

understanding about uric acid. -

etiology of uric acid

mention the etiologi of uric acid 3. The the about client can

Mention of sign 3. Assess the physical and synmptom of uric acid assessment 4. Give healthy health

mention sign and synmptom of uric

Mention

education

food

and

non

uric acid

acid 4. The client can

healthy food for the client with

mention the healthy food and non

uric acid Mention the

healthy food for the clien with uric acid 5. The client can the

healthy food and non healthy food for the patient

mention

with uric acid. Mention traditional treatment for uric acid. the

traditional treatment for client with uric acid.

IMPLEMENTATION OF NURSING CARE with Mr. M ESPECIALLY Mrs. J DATE

November, 24th 2012

TIME
18.00

DX. NO
1,2 R/ S: -

IMPLEMENTATION AND RESPOND

Making trash with client and her family

SIGNATURE

The client said about her name The client introduce her family The client said about her family history The client said that