NURSING CARE PLAN C R E A T E D BY ANNISHA RAHMANI P3.73.20.1.10.

090
SUPERIOR PROGRAMME OF INTERNATIONAL LEVEL MAJOR OF NURSING POLYTECHNIC OF HEALTH JAKARTA III

NURSING ASSESSMENT
A. CHARACTERIATIC 1. Head of Family identity Head of familys name Gender Age Religion Education Occupation Address Telephone Number : Mr. M : Male : 48 years old : Muslim : Elementary School : Farmer : Rt. 001 Rw 025 Dusun Sengir, Sumberharjo Village :-

2. Structure of family
RELATIONSHIP NO NAME AGE GENDER WITH HEAD OF FAMILY EDUCATION OCCUPATION PROBLEM OF HEALTH

Mr. Marzuki

48

Male

Husband

Elementary School

Farmer

Mrs. Juaridar 47

Female

Housewife

Elementary School

Farmer

2 months ago has high blood sugar/ DM, Asam Urat

Miss. Mukti

20

Female

Child

Senior High School

Seller

Migren dna hipotensi

Abdullah S.

15

Male

Child

Junior High School

Student

Tika Q

12

Female

Child

Elementary school

Student

Putri Rifa

Female

Child

Play Group

Student

3. Genogram

MRS. J

MR. T

Miss. M 20thn

Mr. Abdullah 15 thn

Miss. T 12 thn

Miss. P 9 thn

B. THE STAGES OF FAMILY DEVELOPMENT The client said that the client has good communication each other. The client said that one of them have good mutual interaction and always help each other if there are need some helps. The history of nuclear family in Mr. M that Mrs. J has several complain like that several months before Mrs. J gets high blood glucose and uric acid. Their daughter, Mrs. M has hypotension and migren.

C. FAMILY STRUCTURE Actually the client has long time for interaction at night when all part of in family comes. The interaction will happen when they were watched television. There is not obstacle for interaction one each other. The client said that there is no conflict in the family problems when the interaction occurred. The client said that they use Java language for doing communication. When they have problems in their family, the client said that they always discussion for finding the solution. Mr. T is the person who made decision. In Mr. T family if they have problem sometimes they never asking another for getting helped. Both of Mr. T and Mrs. J come from Central Java. They never have or adopt the traditional value from their culture and religion. The Mr. Ts family has perception about health. They will care if there are one from them get illness but they have lack of information about their health to keep it. Mr. T as a father has several role such as making decision after discussion with other. Mrs. J as a mother has several roles that she must to manage her children and all every things which they need it. There are the conflict of role like her children should be worked because they dont has enough money for continuing her study.

D. FAMILY FUNCTION The respond of family if there are someone gets success is happy. And respond from his family if the losing part of family is try to accept their condition. Miss. Mukti follow the organization in Dusun Sengir : Karang Taruna. Mr. Ts family never has conflict with another person in around their house. And when Mr. Ts family has problem in their health actually they use midwife in their village

and use public health center to follow up their status of health. There is no one of Mr. Ts family which has specially skill and all Mr. Ts family has ability to read and write. Mrs. J follow family planning, she use injection every 3 months. The reason why she use injection because she afraid if she forget to take pill before doing sexual interaction. There is no complain about contraception equipment.

E. STRESSOR AND COPPING Several person in Mr. Ts family has get salary. There are Mr. T, Mrs. J and Miss. M. The totally salary which they have approximately < 920.000. Their routine expenditure are daily needs, the need for food, the cost of taxes, school fees and transport costs. They feel enough to fulfil their necessity. And Miss. Mukti has been spent her salary in bank. Mrs. J always provide food to cook your own food that you want to eat. She always cooks provide vegetables, side dish and staple foods such as rice. since his son was little, Mrs. J did not provide milk for his or her child will not drink milk. clients always serve food with closed so that no infestation by flies. The clients always serve food with closed so that no infestation by flies. In the family of Mr. M, Miss Mukti has an allergy to food is prawns. The clients have a habit of cooking beverages that they want to drink. Besides that the client also has a habit of cutting first, then wash it thoroughly. Mr. M also has habits to eat together. Mrs. J has habit to take a nap. Not all the children has private bedroom. Mr. M and his family did not have the habit to go for recreation because economic constraints and busy right of every member of society.

F. FAMILY DEGREE Mrs. J has high blood glucose and uric acid. It one of stressor for Mr. M family but they still handle by themselves. And they have been commit if there are one of their family has big problem will solve the problem together. Mrs. J health problems is high blood sugar and uric acid. And no experience of disability in the family Mr. M.

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.

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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