ASUHAN KEPERAWATAN PADA PASIEN DIABETES MELITUS

Oleh:
Nama : Rosna wali
Npm : 1420118098
Kelas : Siang (Ambon)
Semester : VI
Prodi : Keperawatan

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN
MALUKU HUSADA
AMBON
2020
A. ASSESSMENT
Study Date : December 5, 2018
Room : Alamanda.
 Client Identity

Name : Mrs. R

Age : 50 years

Female gender

Address : Andai River, Banjarmasin

Islam

Status : Married

Ethnic/Nation : Banjar/Indonesia

Occupation: Private

Medical diagnosis: Diabetes Mellitus type II

RM Number : 18.11.59

Entry date : 5 December 2018

Responsible Identity

 Name : Mr. D

Male gender

Address : Andai River, Banjarmasin

Hubs. With client: Husband

1. Main complaint
The client said his legs felt tingling and felt heavy to walk.
2. History of Present Disease
The client said two days ago his head was dizzy, it felt like he was being stabbed. The
client says he is weak and when he walks he feels heavy. Feet often feel tingling.
Then checked at the Puskesmas in the Sungai Andai area, the GDS score was 411.
The puskesmas recommended the client to check at the hospital polyclinic. The client
checked himself at the ULIN Hospital on December 5, 2018, the results obtained were
GDS 298, blood pressure 130/80 mmHg, pulse 88x/minute. The client was advised to
be hospitalized, the diagnosis was type II diabetes mellitus.
3. Past medical history
The client had kidney stone surgery one year ago.
4. Family Disease History
The family has no history of diabetes mellitus and other hereditary diseases.
5. Physical examination

 Vital sign

June 19, 2012

Blood pressure: 120/80 mmHg
Pulse: 88 beats/minute
Breathing: 18 times/minute
Temperature : 37,5°C

 Skin

Brown skin color, swelling on the right and left legs, dry skin, poor skin turgor in the
lower extremities.

a. Head and Neck

 Head shape: mesocephalic.

 Hair: gray hair, long, curly, thin, spread
 evenly, no lesions.
  Eyes: symmetrical, non-icteric sclera, anemic conjunctiva, the eyelids are not
black, good vision.
 Ears: symmetrical, no abnormal output.
 Nose: no secretions, no lesions, no masses.
 Mouth: No canker sores, dry lip mucosa, none

bleeding gums.

 Neck: no enlargement of the thyroid gland and lymph nodes.

b. Lungs
 Inspection: symmetrical, chest expansion is not maximal.
 Palpation: symmetrical expansion of the right and left lungs.
 Percussion: sonor.
 Auscultation: no whezzing and rhonchi.
c. Abdomen
 Inspection: no lesions, brown skin color.
 Auscultation: bowel sounds 10 times / minute.
 Palpation: no mass, no lump.
 Percussion: tympanic.

d. Extremities

1. Look
 Upper extremity

The skin color is tan and even, the skin is dry, there is no edema in the
right and left palms, there are no fractures and deformities.

 Lower Extremities

Brown skin color, swelling on the back of the right and left legs, no
fracture and deformity.
2. Feel

 Upper extremity
There is no tenderness in the right and left upper extremities, no
numbness, no tingling.
  Lower Extremities

There is tenderness on the back of the right and left legs, the pain feels
throbbing and sometimes suddenly feels like an electric shock, sometimes
feels tingling, the client says the pain scale is 4, the frequency of pain is
often felt.

3. Move
 Upper Extremities:
Right and left hands can be moved. The client's right and left hands are
able to defy gravity and resistance, able to perform flexion-extension,
pronation-supination, and rotation.
 Lower Extremities:

Right and left legs can be moved. The right and left feet are able to defy
gravity and resistance but are not maximal, unable to do flexion-extension,
dorsiflexion-plantarflexion. There is swelling in the back of the right and
left legs..

6. Functional Assessment

 Perception of health-health management

The client said that when he was sick, he always went to the health center or
doctor. The client said that health is a condition of the body that can do anything,
while illness is a condition of a weak body. The client does not drink alcohol,
does not smoke, does not use drugs.

 Oxygen Needs

The client does not appear to have shortness of breath, no nostrils, no cyanosis,
no cough. No whezzing sound, crackles.

 Nutritional and Fluid Needs

Before being admitted to the hospital, the client said he ate 5 times a day, his
appetite had increased since 1 month ago. The client said he didn't really like
vegetables. The client said that he drank approximately 6-7 glasses per day.
 Before the illness, the client's height was 155 cm, weight was 54 kg. The client
said he had gained weight for 1 month from 54 kg to 60 kg.

When sick the client gets a diet of porridge without sugar and low sugar. Upon
admission to the hospital, the client's weight decreased to 58 kg.

 Elimination Needs

Prior to admission to the hospital, the client said to eliminate urine ± 7-8 times a
day, faecal elimination 2 times for ± 1 day (diarrhea) for 3 days. Upon admission
to the hospital, the frequency of urinary elimination was slightly reduced to 5-6
times a day, faecal elimination 1 time a day with a mushy consistency.

 Need for rest and sleep

Before getting sick, the client's family said the client's sleep frequency was ± 8
hours / day, with good sleep quality and no sleep disturbances (insomnia,
parasomnia). Upon admission to the hospital, the client's sleep frequency
increases, ± the client sleeps about 10 hours/day.

 Personal Hygiene Needs

Before getting sick, the client always takes a bath 2 times a day, diligently
brushes his teeth, and toilets independently. The client washes hair once every 2
days. When sick, the client can perform self-care independently, such as bathing,
toileting, but in terms of dressing the client needs the help of others.

 Recreational and Spiritual Needs

Before entering the hospital, the client said he liked to go for walks, watch
television and garden. The client is diligent in praying 5 times. When entering
the hospital, the client can only pray.

B. DATA ANALYSIS
 DATA ETIOLOGY NURSING DIAGNOSES
DS :
- The client said swelling
in the back of the right
and left legs.
- The client said he
already knew that the
client had DM.
Risk for ineffective
Diabetes Mellitus peripheral tissue perfusion
DO :
related to diabetes mellitus
- Swelling in the back of
the right and left legs.

- Vital signs: blood

pressur120/80 mmHg, pulse
88 times/minute, respiration
18 times/minute, temperature
37.5°

C. INTERVENSI

DIAGNOSA
N
KEPERAW NURSING CARE PLAN
o.
ATAN
Risk for Result criteria Interventio Rational
NOC : NIC :
ineffective
 Tissue  Observe the presence  To identify areas
peripheral
perfusion: of certain areas that sensitive to
tissue
cerebral are only sensitive to heat/cold/sharp/blun
perfusion
DESTINA heat/cold/sharp/blunt t

1. TION : .  To find out

 After  Monitor for inflammation and
nursing for thrombophlebitis. pain
2 x 24  Collaborative  To reduce pain.
hours there administration of
is no analgesics.
disturbance
 in the
patient's
circulation
status
status
CRITERIA
 Systore and
diastolic
pressures
within the
expected
range
 No
orthostatic
hypotensio
n

D. IMPLEMENTASI

No. Hari / Diagnosa

Jam Implementasi Evaluasi TTD
Tanggal Keperawatan
1. Kamis / 6 08.00 Resiko  Mengamati S : pasien
Desember – ketidakefektifan keberadaan mengatakan
2018 08.10 perfusi jaringan daerah-daerah bahwa masih
perifer tertentu yang ada area yang
hanya sensitif sensitif
terhadap terhadap
panas / dingin panas / dingin
/ tajam / / tajam /
tumpul. tumpul
 O : Pasien tidak
merasa sakit
ketika dicubit
pada sisi
perifer.
A : masalah
belum teratasi
P : Intervensi
dilanjutkan.

Kamis / 6 09.00 Resiko  Memonitor S : Pasien

Desember – ketidakefektifan untuk mengatakan
2018 09.10 perfusi jaringan thromboplebit tidak ada
perifer is. pembengkaka
n, kemerahan,
dan rasa sakit
di kaki dan
lengan.
O : Tidak ada
pembengkaka
2.
n, kemerahan,
dan nyeri di
kaki dan
lengan pasien.
A : Masalah
teratasi.
P : Intervensi
dilanjutkan.

Kamis / 6 10.10 Resiko  Berkolaborasi S : Pasien

3. Desember – ketidakefektifan pemberian mengatakan
 2018 10.20 perfusi jaringan analgesik. tidak
perifer merasakan
sakit.
O : Pasien tidak
merasa sakit
saat
dipalpasi.
A : Masalah
teratasi.
P : Intervensi
selesai.

E.EVALUASI

Hari / Diagnosa
No Jam Evaluasi
Tanggal Keperawatan
1. Selasa / 11 08.00 Resiko S : Pasien mengatakan bahwa tidak
ada lagi area yang hanya sensitif
Desember – ketidakefektifan
terhadap panas / dingin / tajam /
2018 08.20 perfusi jaringan tumpul dan pasien juga
mengatakan tidak ada
perifer
pembengkakan, kemerahan, dan
nyeri pada kaki, lengan dan
lainnya.
O : Pasien merasakan nyeri ketika
terjepit, tidak ada pembengkakan,
kemerahan dan rasa sakit di kaki
dan lengan pasien dan pasien
tidak merasa sakit ketika
 dipalpasi.
A : Masalah teratasi.
P : Intervensi selesai.