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

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

Marzuki 48 Male Husband Elementary School Farmer - 2 Mrs. Mukti 20 Female Child Senior High School Seller Migren dna hipotensi 4 Abdullah S.NURSING ASSESSMENT A. 15 Male Child Junior High School Student - 5 Tika Q 12 Female Child Elementary school Student - 6 Putri Rifa 9 Female Child Play Group Student - . Head of Family identity Head of family’s name Gender Age Religion Education Occupation Address Telephone Number : Mr. M : Male : 48 years old : Muslim : Elementary School : Farmer : Rt. Juaridar 47 Female Housewife Elementary School Farmer 2 months ago has high blood sugar/ DM. CHARACTERIATIC 1. Sumberharjo Village :- 2. 001 Rw 025 Dusun Sengir. Asam Urat 3 Miss. Structure of family RELATIONSHIP NO NAME AGE GENDER WITH HEAD OF FAMILY EDUCATION OCCUPATION PROBLEM OF HEALTH 1 Mr.

Abdullah 15 thn Miss. M 20thn Mr. J MR. Genogram MRS.3. T 12 thn Miss. P 9 thn . T M A T P Miss.

In Mr. Both of Mr. The client said that there is no conflict in the family problems when the interaction occurred. J as a mother has several roles that she must to manage her children and all every things which they need it. They will care if there are one from them get illness but they have lack of information about their health to keep it. T and Mrs. The client said that they use Java language for doing communication. Mrs. FAMILY FUNCTION The respond of family if there are someone gets success is happy. D. Miss. They never have or adopt the traditional value from their culture and religion. THE STAGES OF FAMILY DEVELOPMENT The client said that the client has good communication each other. And when Mr. M that Mrs. Mrs. the client said that they always discussion for finding the solution. T family if they have problem sometimes they never asking another for getting helped. C. T as a father has several role such as making decision after discussion with other. T’s family has perception about health. When they have problems in their family. FAMILY STRUCTURE Actually the client has long time for interaction at night when all part of in family comes. Mr. The Mr. T is the person who made decision. M has hypotension and migren. J gets high blood glucose and uric acid. The client said that one of them have good mutual interaction and always help each other if there are need some helps. J has several complain like that several months before Mrs. And respond from his family if the losing part of family is try to accept their condition. Mr.B. T’s family never has conflict with another person in around their house. There are the conflict of role like her children should be worked because they don’t has enough money for continuing her study. J come from Central Java. The history of nuclear family in Mr. There is not obstacle for interaction one each other. T’s family has problem in their health actually they use midwife in their village . Mukti follow the organization in Dusun Sengir : Karang Taruna. Mr. Their daughter. The interaction will happen when they were watched television.

FAMILY DEGREE Mrs. . 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. T. And Miss. J has habit to take a nap. T’s family has ability to read and write. the cost of taxes. J has high blood glucose and uric acid. E. since his son was little. Mr. J did not provide milk for his or her child will not drink milk. Mrs. The clients have a habit of cooking beverages that they want to drink. And no experience of disability in the family Mr. school fees and transport costs. Mrs. Miss Mukti has an allergy to food is prawns. STRESSOR AND COPPING Several person in Mr. M also has habits to eat together. The clients always serve food with closed so that no infestation by flies. Mrs. Not all the children has private bedroom. The reason why she use injection because she afraid if she forget to take pill before doing sexual interaction. M. clients always serve food with closed so that no infestation by flies. Mrs. In the family of Mr. Mrs. J always provide food to cook your own food that you want to eat. Mrs. F. M. J and Miss. Besides that the client also has a habit of cutting first. Their routine expenditure are daily needs. the need for food. Mr.000. There is no complain about contraception equipment. There is no one of Mr. M. J follow family planning. then wash it thoroughly. T’s family has get salary. Mukti has been spent her salary in bank. The totally salary which they have approximately < 920. side dish and staple foods such as rice. She always cooks provide vegetables.and use public health center to follow up their status of health. T’s family which has specially skill and all Mr. It one of stressor for 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. There are Mr. J health problems is high blood sugar and uric acid. she use injection every 3 months. They feel enough to fulfil their necessity.

ASSESSMENT FOCUS DATA a. 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 . b. 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 doesn’t 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 doesn’t know the asam urat The client said that the client doesn’t know the reason or etiology from asam urat The client said that when the pain comes the client only massage with their oil.

3 kg - Uric acidvalue is 9.6o celcius .= 55/(2.35 IBW = (TB-100)-10% (TB-100) = (157-100)-10% (157-100) = 57-5.46) = 22.6 mg/dl Blood Pressure 110/ 70 mmHg Respiratory Rate 24x/menit Pulse 80x/menit Temperature 36.7 = 51.

Objective Data : General condition of client looks good The client 47 years old The client looks tired The client looks sweaty The client doesn’t answer the question about her disease . M family The client said the blood glucose of especially Mrs. 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.ANALISA DATA NO 1. - DATA FOKUS Data Subjektif : The client said that feels tired MASALAH Knowledge about her disease her ETIOLOGY disease in Mr. Mr. 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 didn’t know about the reason of high blood glucose The client said that she never control at public health cervices because she feels get better.

- 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 = 50.35 - IBW = (TB-100)-10% (TB-100) = (157-100)-10% (157-100) = 57-5. 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 family family especially Mrs.7 = 51.6o celcius 2.46) = 22.5 kg Body weight after illness = 55 kg BMI = BB/ (TB)2 = 55/(2. J sick - The client said that her legs feels tingling - The client said that her legs feels numbness The client said that she doesn’t has uric acid The client said that the client didn’t know about uric acid The client said that doesn’t know - - - . J - The client said that her legs feels so especially Mrs.3 kg - Blood Pressure 110/ 70 mmHg Respiratory rate 24x/menit Pulse 80x/menit Temperature 36. M cramps in Mr.

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. 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.about the causes of uric acid The client said that when the pain comes the client only give the massage oil (minyak kayu putih.6o celcius .

J problems that looking difficult for changing because the client’s family said that it difficult if change the eat pattern. A client is caused by eating poorly controlled. J NO 1. Mrs. 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. J and her family has perception that when the medicine therapy was finished. Possible the problem 2 for changing :  Easy = 2  Partial = 1  Difficult = 0 3.FORM THE PRIORITY OF NURSING DIAGNOSE IN FAMILY Name : Mrs.  Potential =1 2. 4. Mrs. 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 1 0/2 x 1 =0 Related to the priority of health problem. J feel better so she didn’t need to control in public health care. 2 2/3 . 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) ½x2= 1 Based on Mrs. Clients say that the client is very difficult to control her diet.

 Potential =1 2.FORMAT THE PRIORITY OF NURSING DIAGNOSE IN FAMILY Name : Mrs. J and her family think that is not important to go to public health service because clients and his own family 4. 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. Possible the problem for changing :  Easy = 2  Partial = 1  Difficult = 0 2 ½x2=1 Clients just massaging her legs. she feels pain on her joint. Mrs. J NO 1. 1 0/2 x 1 =0 Related to the priority of health problem. 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. Mrs. Based on the result of uric acid diagnostic test.6 – 6 mg/dl. 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 3.6 mg/dl while the normal value of uric acid for women is 2. 2 1/3 . Potential prevent the problem  Height = 3  Middle = 2  Lower = 1 experienced. the client’s score is 9. J’s problem is said to be changed partly because the family does not know how to solve the health problems that occur.

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