NURSING CARE IN NY.

"A"

WITH MEDICAL DIAGNOSIS " DIABETES MELLITUS TYPE II "

IN THE TANJUNG AN ROOM OF THE PROVINCE NTB

OLEH :

NAME: PURNATIKA

NIM: PO71420421120N

CLASS: B

KEMENTRIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN MATARAM

JURUSAN KEPERAWATAN PRODI PENDIDIKAN NERS

TAHUN 2021
 NURSING CARE IN NY. "A"

WITH MEDICAL DIAGNOSIS " DIABETES MELLITUS TYPE II "

IN THE TANJUNG AN ROOM OF THE PROVINCE NTB

I. NURSING DIAGNOSIS
Name: NY. “A” Room : Tanjung An (04)

Age : 50 year No. Rm : 034936

A. ANALISA DATA
NO DATA ETIOLOGI PROBLEM
1. DS: Physical Injury Agent Acute Pain
1) The client said pain
in his injured leg
2) The family said the
patient was
uncomfortable with
the wound
DO:
1) Client grimacing in
pain
2) Pain scale 7
3) The client looks
restless
4) There is tenderness
in the injured leg area
5) The client seems to
move the painful part
when the foot is
touched
2. DS: Resistensi insulin Blood sugar instability
1) The patient said the
body is weak and
tired
2) The patient said that
often feels thirsty
3) The Patients said
often urinate as much
 as +-10 times
DO:
1) Blood sugar patient
is 284
2) The client looks tired
3) The client seems to
urinate frequently
4) Clients seem to
drink frequently

B. Nursing Diagnosis Formulation

1. Acute Pain related to Physical Injury Agent as evidenced by the client said
pain in his injured leg, The family said the patient was uncomfortable with
the wound, Client grimacing in pain, Pain scale 7, The client looks restless,
There is tenderness in the injured leg area, The client seems to move the
painful part when the foot is touched
2. Blood sugar instability related to Resistensi insulin as evidenced by The
patient said the body is weak and tired, The patient said that often feels
thirsty, The Patients said often urinate as much as +-10 times, Blood sugar
patient is 284, The client looks tired, The client seems to urinate frequently,
Clients seem to drink frequently.
 II. INTERVENTION
N NURSING
O DIAGNOSIS
1 Acute Pain related
to Physical Injury
Agent
2 Blood sugar
instability related to
Resistensi insulin
GOAL
After nursing action 3
x24 hours it is expected that
the pain will decrease with
the following criteria:
• Decreased pain level
• Wound healing improves
• Decreased injury rate
After nursing actions for 3 x 1) Management of hyperglycemia:
24 hours, the instability of
blood sugar improves with
the following criteria:
• Stability of blood glucose
levels improves
• Improved nutritional status
• Knowledge level increases
INTERVENTION
1) Pain management
Observation :
- Identification of location
identification, characteristics,
duration, frequency,quality, intensity
of pain
- Identify pain scale
Therapeutic:
- Provide non-pharmacological
techniques to reduce pain
Education:
- Explain the causes and periods and
triggers of pain
Collaboration
- Collaborative administration of
analgesics
2) Education in deep breathing
techniques
Observation :
- Identify readiness and ability to
receive information
Therapeutic:
- Provide health education materials
and media
Education:
- Explain the purpose and benefits of
deep breathing techniques
- Explain the procedure of deep
breathing technique
- Identify possible causes of
hyperglycemia
- Monitor for signs and symptoms of
hyperglycemia
Therapeutic:
- Give oral fluid intake
Education:
 - Promote adherence to diet
Collaboration :
- Collaboration administration of
insulin 6 Iu
2) Educational treatment program
Observation :
- Identification of recommended
Therapeutic treatment:
- Provide support to undergo a
treatment program properly and
correctly
Education:
- Explain the benefits and side
effects of treatment
- Advise to take medication as
indicated
 III. IMPLEMENTATION AND EVALUATION

DAY/DATE DX HOU MPLEMENTATION EVALUATION

R
Monday, 3 I 08.00 1) Perform pain management S:
may 2021 Observation :  The client said pain in the
- Identify identification of the location, injured leg
characteristics, duration, quality of  The client said the pain comes
pain and goes
- Identify pain scale  client said pain during 30
Therapeutic: seconds
- Provide non-pharmacological  The family said the patient
techniques to reduce pain was uncomfortable with the
Education: wound
- Explain the causes and periods and  The client does not
triggers of pain understand the deep breathing
Collaboration technique
- Collaborating on administering O:
analgesics  The client looks grim with
08.30 2) Conducting deep breathing pain scale 7
technique education  The client seems unable to
Observation : perform deep breathing
- Identify readiness and ability to accept techniques
information A : The problem has not been
Therapeutic: resolved, acute pain
- Provide health education materials P: intervention continues
and media Education: 1)Perform pain management
- Explain the purpose and benefits of 2) Doing deep breathing
deep breathing techniques technique education
- Explain the procedure of deep
breathing technique

II 09.00 1) Perform management of S:

hyperglycemia
Observation :
- Identify possible causes of
hyperglycemia (by asking how the
client’s diet)
- Monitor signs and symptoms of
hyperglycemia (by asking if you are
often thirsty and hungry and often
 The patient said he could not
control his eating pattern
 The patient says that he often
feels thirsty
 Patients often urinate as
much as ± 10 x
 The client’s family says the
client is taking medicine
 urination O:
Therapeutic:  Fasting blood sugar,284
- Provide oral fluid intake (give drink to  The client seems unable to
the patient) control his eating pattern
Education:  The client looks tired
- advocating adherence to the diet  Client without frequent
Collaboration: urination
- collaborate on the administration of  Clients seem to drink
insulin as much as 6 units frequently
2) Conduct treatment program A: The problem has not been
09.30 education resolved
Observation : P: the intervention is continued
- Identify recommended treatment (by 1) Perform hyperglycemia
asking if the client regularly takes management
medication) 2) Conduct treatment program
Therapeutic: education
- Provide support to undergo a
treatment program properly and
correctly
Education:
- Explain the benefits and side effects
of treatment
- Advise to take medication as
indicated
Tuesday, 4 I 14.00 1) Perform pain management S:
May 2021 Observation :  The client said the pain in the
- Identify identification of the location, injured leg has begun to
characteristics, duration, quality of decrease
pain  The client says the pain
- Identify pain scale comes and goes with the
(client pain scale) intensity of pain for 30
Therapeutic: seconds
- Provide non-pharmacological  The family said the patient
techniques forreduce pain was uncomfortable with the
Education: wound
- Explain the causes and periods and  The client has begun to
triggers of pain understand the deep
Collaboration breathing technique
- Collaborating on administering O:
analgesics  The client is grimacing with a
2) Conducting deep breathing pain scale of 5-6 .
 14.30 technique education  the client looks restless pain
Observation : in the right leg
- Identify readiness and ability to  The client seems to be able to
accept do deep breathing techniques
Therapeutic information: A : Problem partially resolved
- Provide health education materials P: intervention continues
and media 1) Perform pain management
Education: 2) Teaching deep breathing
- Explain the purpose and benefits of techniques
deep breathing techniques
- Explain the procedure of deep
breathing technique
II 15.00 1) Perform hyperglycemia S:
management  The patient said that he had
Observation : started to control his eating
- Identify possible causes of pattern
hyperglycemia (by asking how the  The patient often feels thirsty
client's diet)  Patient says urinate± 7 x / per
- Monitor signs and symptoms of
day
hyperglycemia (by asking if you are
often thirsty, hungry and often  The client said that he had
urination started to take medicine
Therapeutic: regularly
- Provide oral fluid intake (give drink to O:
the patient)  Fasting blood sugar 250
Education:
 The client seems to have
- advocate adherence to diet
Collaboration : started to control his eating
- collaborate on the administration of pattern
insulin as much as 6 units  The client looks tired
2) Conduct treatment program A: Partially resolved problem
education P: the intervention is continued
15.30 Observation : 1) Perform hyperglycemia
- Identify recommended treatment (by management
asking if the client regularly takes 2) Educate treatment program
medication)
Therapeutic:
- Provide support to undergo a
treatment program properly and
correctly
Education:
- Explain the benefits and side effects of
treatment
- Advise to take medication as indicated
Wednesday I 09.00 1) Perform pain management. S:
, 5 May Observation: • the client says the pain is
2021 - Identify identification of the location, reduced
characteristics, duration, quality of pain • The family said the patient
- Identify pain scale was uncomfortable with the
Therapeutic: wound
- Provide non-pharmacological • The client already
techniques for reduce pain understands the deep
Education: breathing technique
- Explain the causes and periods and O:
triggers of pain • Pain scale 3-4
Collaboration • the client seems to have
- Collaborating on administering started to do deep breathing
analgesics techniques
09.30 2) Conducting deep breathing A: The problem is solved acute
technique education pain
Observation : P: the intervention is stopped
- Identify readiness and ability to accept
information
Therapeutic:
- Providing health education materials
and media
Education:
- Explain the purpose and benefits of
deep breathing techniques
- Explain the procedure of deep
breathing technique
II 10.00 1) Perform hyperglycemia S:
management  The patient said that he could
Observation : control his eating pattern
- Identify possible causes of • Patient says urinaring ±
hyperglycemia (by asking how the 5x/day
client's diet) • The family said they had
- Monitor signs and symptoms of regularly taken medication
hyperglycemia (by asking if you are O:
often thirsty and hungry and urinate • Fasting blood sugar ,184
frequently). • The client seems to be able to
Therapeutic: control eating patterns
- Provide oral fluid intake (give drink to • The client looks tired
the patient) A: Problem solved
Education:
 - advocating adherence to the diet Q: the intervention is
Collaboration: discontinued
- collaborate on the administration of (patient goes home)
insulin as much as 6 units
11.30 2) Conduct treatment program
education
Observation :
- Identify recommended treatment (by
asking if the client regularly takes
medication)
Therapeutic:
- Provide support to undergo a
treatment program properly and
correctly
Education:
- Explain the benefits and side effects of
treatment
- Advise to take medication as indicated