ENGLISH TASK

CASE REPORT NURSING

Lecturer : Rizky Gumilang Pahlawann, S.Kep., M.kep

Created By :
Tia Aprilia 1120002
Syifa Nurul 1120004
Sintia Aprilia 1120005
Isnaini Yulianti 1120006
Syipa Ussuril 1120008
Rissa Amalia 1120009
Tia awaliyah 1120010
Sarah Fadilah 1120011
Vina Rahmawati 1120012
Marbun,Pebriyani 1120013
Fitria Anggraeni 1120015
Vani Noviani 1120016
Cahyawati 1120017
Rizky yuli 1120018
Bella Aurelia 1120019
Nurul Syifa 1120020
Mela Andriana 1120021
Gina Risma 1120023
Sherly Silvi 1120024
Fiorina Erin 1120025
Tegar Surya 1120026
Neng ciwi 1120027
Siti alvi 1120028

NURSING FACULTY
INSTITUT KESEHATAN RAJAWALI
2021
A. Nursing Assessment
1. General data
a. Name : Mr. M
b. Job : Farmer
c. Education : SD
d. Religion : Islam
e. Address : Ds. Nekudu
f. Date of review : May,28 2018
g. Composition of Family Members
Table 3.1 Composition of Family Members
Immunization status
Name gender Age Education BCG DPT Polio Hts Cmpk
Mr. M L 33 Elemantary √ √ √ √ √
years school
old
Mrs.U P 29 junior high √ √ √ √ √
years school
old
An.M L 12 Elemantary √ √ √ √ √
years School
old
An.M P 10 √ √ √ √ √
years
His P 54 Elemantary √ √ √ √ √
years School
old

h. Current medical history

1) Chief complaint of the family:
Mrs. A was escorted by her family to the Asinua Health Center on
28 May 2018 at around 09.00 with the main complaint of headache.
During the assessment, Mrs. A complained of a headache.
Complaint history:
P: Mrs. A said that the complaints were due to her blood pressure
rising again.
Q: Mrs.A said that she felt like she was under pressure from a heavy
 object
R: Mrs. A said the complaints were felt in the head and neck area S:
Pain scale 6 (moderate)
Q: Mrs. A said that the complaints came on suddenly, the headaches
that were felt came and went
 2) Accompanying complaints: Mrs. A said that the head hurts with
dizziness, neck pain and feels heavy.
Check Up results: Mrs. A looked grimaced, Mrs. A looked restless.
i. Genogram

GI

G.II K

G.III

Information :

: Man : Woman
: Die
: Line of descent
: Stay at home
: Sick family member (Mrs. A)

j. family type
A big family consists of father, mother, children and grandmother
k. Tribes
All members of Mr. M's family are Tolaki.
l. Religion
All family members are Muslim
m. Socio-economic status
Mr. M works as a farmer, Mrs. U as a housewife and Mrs. A sells
(grocery food stalls). Family income in a month ± 2,000,000.
n. Family leisure activities
Mr. M's family only goes for recreation once a year, and the family gets
entertainment from watching TV.
2. Family Development Stage History
a. Stages of family development
The current stage of family development is school children (families with
schoolchildren)
b. Family development tasks
1) Completed family development tasks:
Encourage their developing children to be more independent and
create a healthy environment.
2) Unfulfilled family developmental tasks: All family developmental
tasks have been fulfilled
c. nuclear family history
The family said that no members of the nuclear family suffered from
hereditary diseases or had certain diseases.
d. Previous family history
Mr. M said that only Mrs. A suffered from hypertension, her previous
family, both husband and wife, had never experienced the same health
complaints/problems as Mrs. A.
3. Environment
a. House characteristics
The type of house is semi-permanent, the status of the owner of the house
is privately owned by Mr. M with 4 rooms, 1 bathroom, 1 kitchen, tin
roof, living room floor and ceramic middle. The house has adequate
ventilation and good air circulation and good lighting. The family's water
source is a well, with clean and odorless conditions. The distance between
the bathroom and the well is ± 10 meters.
b. House Design

R.GUEST K.4

DAP
K.2 UR
K.1 K.3

R.GUEST
 c. Neighborhood and community characteristics RT/RW
There are no special characteristics of neighbors or communities,
neighborly relations and communities run in harmony, there are no
special rules that bind individuals in society as long as they do not cause
unrest for other communities.
d. Family geographic mobility
Mobility of families using motorbikes. If you want to go to the
Puskesmas, Mrs. A will be accompanied by a child, namely Mr. M. The
family does not have the habit of changing places of residence
e. Family gatherings and interactions with the community
There are no family gatherings, family interactions with the community
are good, interactions between residents are mostly done at the end of
praying together at the mosque and in the afternoon on the terrace of the
stall.
f. Family support system
If there is a problem, the family will resolve it by deliberation. Families
take advantage of the health services available in the village, namely the
Puskesmas
4. Family Structure
a. Family communication pattern
Mr. M's family always communicates well and always communicates
with other families, the everyday language used is Tolaki and Indonesian.
Communication is done in an open way, if there is a problem then the
family will resolve it by deliberation.
b. Family power structure
Decision making in the family is done by deliberation of all family
members. Mr. M as the head of the family has the power to control and
influence family members to change behavior.
c. Role structure
Formal role: Mr. M acts as the head of the family and Mrs. U as the
deputy head of the family.
 Informal roles: Mr. M has the responsibility to earn a living, Mrs. U is a
housewife and Mrs. A has a fairly influential role in the family, and Mr.
M's children.
d. Values and norms
In Mr.M's family there are no special values and norms that bind family
members, for family health problems there is also no practice to do. The
value system adopted is influenced by customs and religion.
5. Family Function
a. Affective function
Mr. M's relationship with his wife, mother and children is well
established, family members respect, care for, love and encourage each
other.
b. Socialization function
Interaction in the family is intimately and disciplined, getting to know
each other with other people.
c. Reproductive function
Mr. M has 2 children, the family controls the number of children by
participating in the family planning program (KB).
d. Economic function
Mr. M works as a farmer to meet the needs of clothing, food and shelter.
Mrs. A also helped support the family's economy by selling (staple food
stalls). Families take advantage of existing health services, families use
KIS cards for treatment.
e. Family health care function
1) Family ability to recognize problems
a) The family said they did not know about hypertension
b) Mrs.A said that she still often consumes excessive salt
c) Mrs. A said that she still often consumes coconut milk, salted fish.
Assessment results:
a) Mrs. A and family can't remember
 b) Mrs. A and her family looked confused and did not understand
when asked about hypertension.
2) The ability of the family to make decisions regarding the right action:
The family is able to make the right decisions. The family took Mrs.
A to the Puskesmas.
3) Ability of the family to care for sick family members: Families say
they don't know how to care for sick family members with
hypertension
4) The ability of the family to modify the environment: Families are not
able to modify a good environment for hypertension treatment.
5) Family ability to use health facilities
Families are able to take advantage of existing health facilities,
namely Puskesmas.
6. Stress and Family Coping
a. Short term and long term stressors
1) Short term (< 6 months)
The family said that while she had no serious problems, it was just
that Mrs. A had a headache.
2) Long term (>6 months)
Families say the long-term stressor is to think about the cost of living
and keep their children in school as high as possible and improve the
family's standard of living.
b. Family response to stressors and coping mechanisms used
1) Family response to stressors
The family considers that the health problems experienced by Mrs. A
must receive immediate treatment so that the condition does not get
worse.
2) Coping strategy used
Families take advantage of existing health services to address Mrs.
A .'s complaints
 c. Dysfunctional adaptation strategies
Mr.M's family has never been rude or abusive towards any of his family members and has never threatened to explain
the problem.
7. Family Hope
The family hopes for health workers to provide treatment for recovery to Mrs. A
8. Physical examination
Table 3.2 Family Physical Examination
Data Mr. M Mrs.U An.M An.M His
TTV BP : 130/90 BP: 110/80 TD :- TD :- TD:180/110
N : 76 x/m RR : N : 78x/m RR : N : 84x/m RR : 22 N : 94x/m RR : 22 N: 96x/m RR:
20 x/m S : 36.5 20 x/m S : 37 x/m S : 36.7 C x/m S : 36.5 C 18x/m S : 37 C
C
Head Symmetrical Symmetrical Symmetrical shape, Symmetrical shape, Symmetrical
shape, clean, shape, clean, clean, black hair clean, black hair shape, clean,
black hair black hair black hair with
a little gray

Neck No enlarged No enlarged No enlarged lymph No enlarged lymph No enlarged

lymph nodes lymph nodes nodes nodes lymph nodes
clear clear clear clear clear

axilla No lesions and No lesions and No lesions and No lesions and No lesions and
swelling in the swelling in the swelling on swelling in the swelling in the
axilla axilla axilla axilla axilla
 The chest The chest looks The chest looks The chest looks The chest looks
looks symmetrical, symmetrical, symmetrical, symmetrical,
symmetrical, there are no there are no there are no there are no
there are no additional additional breath additional breath additional
additional breath sounds, sounds, no sounds, no breath sounds,
breath sounds, no lesions and lesions and lesions and no lesions and
no lesions and swelling swelling swelling swellingwill
Chest swelling
in the form of in the form of a in the form of a in the form of a in the form of a
a lump, no lump, no wall lump, no wall lump, no wall lump, no wall
wall retraction retraction retraction retraction retraction
chest chest chest chest chest

Abdomen There is no There is no There is no There is no There is no

ascites, there ascites, there is ascites, there is ascites, there is ascites, there is
is no no tenderness no tenderness no tenderness no tenderness
tenderness and pain loose and pain loose in and pain loose in and pain loose
and pain loose in each each each in each
in each quadrant quadrant quadrant Quadrant
quadrant
Upper No edema, No edema, No edema, No edema, No edema,
extremity movement movement movement movement movement
good good good good Well
 Lower No edema, no No edema, no No edema, no No edema, no No edema, no
Extremities varicose varicose veins, varicose veins, varicose veins, varicose veins,
veins, turgor turgor turgor turgor turgor
good skin. good skin. good skin. good skin. good skin.

B. Data Classification
Head of family : Mr. M Sick Family Members : His
Table 3.3 Focused Data on Family Nursing Assessment Results
Subjective data Objective Data
1. Mrs. A complained of a headache. 1. Mrs. A looks grim
Q: Mrs. A said that the complaints 2. Mrs. A looks restless
were due to her blood pressure 3. Mrs. A and her family can't
rising again. remember.
Q: Mrs.A said that the complaint 4. Mrs. A and her family
felt like being pressured by a looked confused and did
heavy object not understand when asked
R: Mrs. A said the complaints about hypertension.
were felt in the head and neck area. 5. TTV: TD:180/110, N: 96x/m,
S: Pain scale 6 (moderate) RR: 18x/m, S: 37 C.
Q: Mrs. A said that the
complaints came on
suddenly, the headaches that
were felt came and went
 2. Mrs. A said she was dizzy, had
neck pain and felt heavy.
3. The family said they did not
know about hypertension.
4. Mrs.A said that she still often
consumes excessive salt
5. Mrs. A said that she still often
consumes coconut milk, salted
fish.
6. Families say they don't know
how to care for sick family
members with hypertension

C. Nursing Diagnoses
1. Data analysis
Table 3.4 Analysis of Nursing Diagnosis Data
No Data Reason Problem
1 DS : Inability family Acute Pain
1. Mrs. A complained of caring for sick
a headache. family members
Q: Mrs. A said that the
complaints were due to her
blood pressure rising again.
Q: Mrs. A said that the
complaints felt like being
pressured by heavy objects
R: Mrs. A said the
complaints were felt in the
head and neck area
S: Pain scale 6 (moderate)
Q: Mrs. A said that the
complaints came on
suddenly, the headache
that was felt came and
went
2. Mrs. A said she was
dizzy, had neck pain and
felt heavy.
DO:
1. Mrs. A looks grim
2. Mrs. A looked restless.
3. Vital sign.
TD:180/110
N: 96x/m
RR: 18x/m
S : 37 C
 2 DS : Inability family Knowledge
1. The family said they did knows the deficiency
not know about problem
hypertension
2. Families say they don't
know how to care for sick
family members with
hypertension
3. Mrs.A said that she still
often consumes excessive
salt
4. Mrs. A said that she still
often consumes coconut
milk, salted fish.
DO:
1. BP : 180/110 mmHg
2. Mrs. A and family can't
remember
3. Mrs. A and her family
looked confused and did
not understand when asked
about hypertension.

2. Family Nursing Diagnosis Score

a. Acute Pain related to the inability of the family to care for a sick family member Table
3.5 Scoring of Family Nursing Diagnosis Acute Pain
No Criteria Calculation Score Justification
1 nature of the problem: 3x1/3 1 Pain problem
Actual : 3 acute in Mrs. A
felt and
need action
maintenance
2 Possibility 1x2/2 1 Knowledge
problem can be resources and
changed
: Partial : 1 facility
health
available and can
reachable
/used
3 Potential problems 2x1/3 0.6 Pain can
for prevented if
prevented family
enough : 2 know how
care that
Correct
 4 Prominent problem: 2x1/2 1 Troubled
Problems are feeling
felt and by Mrs. A and
need to be addressed could become
immediately more serious if
:2 not addressed
immediately
Total Score 3.6

b. Knowledge deficiency related to the inability of the family to recognize

the problem
Table 3.6 Scoring of Knowledge Deficiency Nursing Diagnosis
No Criteria Calculation Scor Justification
e
1 Nature of 3x1/3 1 Family doesn't
problem : know
Actual : 3 about hypertension

2 Possible problem can 1x2/2 1 With enough

be changed Partially : information, it
1 will add insight
and family
knowledge
about
hypertens
ion
3 Potential to 3x1/3 1 Hypertension is a
Prevent : disease that can
Easy : 3 be controlled if:
family knows

4 Prominent 0x1/2 0 The problem

problem Problem is not felt
not perceived : 0 by Mrs. A and
family
Total Score 3

3. Priority for Family Nursing Diagnosis

a. Acute pain is related to the inability of the family to care for sick family
members, which is related to:
Subjective data :
1) Mrs. A complained of a headache.
 P: Mrs. A said that the complaints were due to her blood pressure
rising again.
Q: Mrs.A said that she felt like she was under pressure from a heavy
object
R: Mrs. A said the complaints were felt in the head and neck area S:
Pain scale 6 (moderate)
Q: Mrs. A said that the complaints came on suddenly, the headaches
that were felt came and went
2) Mrs. A said she was dizzy, had neck pain and felt heavy.
Objective data:
1) Mrs. A looks grim
2) Mrs. A looked restless.
3) Vital sign.
TD:180/110
N: 96x/m
RR: 18x/m
S : 37 C
b. Knowledge deficiency is related to the family's inability to recognize
problems characterized by:
Subjective data :
1) The family said they did not know about hypertension
2) Families say they don't know how to care for sick family members
with hypertension
3) Mrs.A said that she still often consumes excessive salt
4) Mrs. A said that she still often consumes coconut milk, salted fish.
Objective data:
1) BP: 180/110 mmHg
2) Mrs. A and family can't remember
3) Mrs. A and her family looked confused and did not understand when
asked about hypertension.
D. Nursing Intervention
Table 3.7 Family Nursing Interventions
No Nursing diagnoses Objectives and outcome criteria
(NOC)
1 Acute pain related to the NOC : NIC
inability of the family to After 3 home visits, it is hoped that
care for sick family the pain will be resolved.
members. Result criteria:
1. Client is able to control pain
(knows the cause of pain, able
to use non-pharmacological
techniques to reduce pain, seek
help)
2. Reported that pain was
reduced with pain
management.
3. Express a sense of
comfort after the pain is
reduced.
2 Knowledge deficiency NOC :
is related to the After 3 home visits, the family is
family's inability to expected to know about the disease
recognize the problem. process.
Result criteria:
1. Patients and families express an
understanding of the disease,
Intervention
(NIC)
Pain management
1. Assess pain comprehensively.
2. Observation of vital signs
3. Teach/demonstrate pain management techniques
(relaxation techniques)
4. Teach/demonstrate pain management techniques
(distraction)
5. Advise / demonstrate to the client and family
warm compresses on the back of the head.
6. Instruct client to increase rest.
7. Provide a comfortable environment to reduce pain.
8. Inform client and family about pain and treatment
provided.
9. Collaborative administration of pharmacological therapy
(analgesic) to reduce pain (katopril 25 mg)
NIC
Teaching: disease process
1. Assess the client's and family's knowledge about
hypertension
2. Discuss with the family about hypertension using
leaflets covering the understanding of hypertension,
causes, signs and symptoms, disease process,
complications, treatment and prevention of
hypertension.
3. Discuss with the family the decision to care for a
sick family member.
 condition, and
treatment program.
2. Patients and families are
able to carry out the
procedures described
correctly.
3. Patients and families are able
to explain back what the nurse
explained.
4. Clients and families know the
complications of hypertension
4. Discuss with the family how to care for a sick
family member.
5. Explain the foods that people with hypertension should
eat and avoid.
6. Discuss with the family about the environment that
supports health.
7. Discuss with the family about the use of health facilities.
E. Implementation and Evaluation of Family Nursing
Table 3.8 Implementation and Evaluation of Family Nursing
Day Day
Nursing SOAP
Date Implementation Initials Date Initials
diagnoses Evaluation
Hour Hour
Acute pain Mond 1. Comprehensive pain Tuesday Subjective :
related to the ay assessment. 29/5/18 - The client said the pain was still
inability of the 28/5/18 Results : 15.55 felt but it had decreased slightly
family to care for 16.00 Q: Mrs. A said that the (pain scale 4).
sick family complaints were due to - Clients say they are able to control
members. her blood pressure rising pain with relaxation and distraction
again. techniques (clients do pain
Q: Mrs. A said that the distraction techniques by reading
complaints felt like being the Koran).
pressured by heavy objects - The client mentions the cause of
R: Mrs. A said the the occurrence and the pain.
complaints were felt in the - The client said the pain decreased
head and neck area slightly after doing the pain
S: Pain scale 6 (moderate) management techniques taught.
Q: Mrs. A said that the - The client said he felt more
complaints came on comfortable and the pain was
suddenly, the headache reduced after doing a warm
that was felt came and compress on the back of the head.
went Objective :
2. Observe vital signs. - The client is able to demonstrate
Result : relaxation, distraction and
TD:180/110 compression techniques
N: 96x/m
RR: 18x/m
 S : 37 C
3. Teaching/demonstrating n
pain management
techniques (relaxation
techniques).
Results :
DS: The client said he
was willing to be
taught relaxation
techniques
DO : The client follows the
relaxation techniques
taught.
4. Teaching/demonstrating n
pain management
techniques (distraction).
DS : The client said he
didn't know what
a distraction
technique was.
DO: The client seems
to be listening to
the distraction
technique being
taught.
5. Advise/demonstrate on the
client and family warm
compresses on the back of
the head.
Results: Clients and
families are cooperative.
6. Encourage the client to
increase rest.
warm on the back of the
head.
- The client is able to state
the cause of the pain.
- Mrs. A no longer looked
restless and grimaced.
- Vital signs: BP:
150/100.
N : 90 x/m
RR : 18 x/m
S : 36.8 C
A : Problem partially resolved
Planning :
- Assess pain scale
- TTV Observation
- Recommend relaxation
techniques.
- Suggest doing distraction
techniques.
- Recommend giving a warm
compress on the back of the
head.
- Instruct client to increase
rest.
 Results :
DS : The client said he
understood the
instructions given.
DO : Cooperative client.
Seemed to listen
carefully to the
instructions given.
7. Encourage the family to
provide a comfortable
environment for the client
to reduce pain.
Results :
DS : The family said they
understood the
instructions given
DO: Cooperative family.
8. Provide information to
clients and families about
pain and the care provided.
Results :
DS : The client said he was
willing to listen to the
information.
DO : It seems that the
client and family
are listening to the
information
conveyed.
Knowledge Mond 1. Assess the knowledge of
deficiency ay clients and families about
related to the 28/5/18 hypertension.
Results :
inability of the 16.25
DS: The client says
family to
hypertension is high
recognize the
blood pressure.
problem.
DO : The client and family
seem confused when
asked about
hypertension.
2. Discuss with the family
about hypertension by using
leaflets covering the
understanding of
hypertension, its causes,
signs and symptoms, disease
process, complications,
treatment and prevention of
hypertension.
DS : The family said they
were willing to listen to
the information.
DO: Cooperative family.
3. Discuss with family about
decisions to care for sick
family members.
DS : The family said to
take advantage of
Tuesda Subjective :
y - The family said they
29/5/18 understood the disease,
condition, and treatment
16.05
program given to Mrs. A.
- The family said that they
carried out the treatment
program according to the
nurse's description.
- The family mentions the
meaning of hypertension, its
causes, signs and symptoms,
complications, treatment and
prevention of hypertension in
their own language.
Objective :
- The client and family are
able to carry out the
procedures described
correctly.
- Clients and families are able
to re-explain what was
explained but still often forget
and are not fluent.
- Clients and families know the
complications of hypertension
A : Problem partially resolved.
Planning :
- assess family knowledge
about hypertension.
 Puskesmas to treat Mrs. A - Discuss with the family about
DO : Cooperative family hypertension using leaflets
4. Discuss with the family how covering the understanding of
to care for (medication hypertension, causes, signs and
program) sick family symptoms, disease process,
members. complications, treatment and
DS : The family said they prevention of hypertension.
were willing to be - Discuss with the family how to
taught how to take treat (treatment program) sick
care of Mrs. A. family members.
DO: Cooperative family.
5. Explain the foods that
people with hypertension
should eat and avoid.
DS: The client mentions a
good diet for
hypertension.
DO : The client is able to
repeat the
information
submitted.
6. Discuss with the family
about the environment that
supports health.
DS : The family mentioned
a good environment to
support health.
 DO : Families are able to
repeat the
information
submitted.
7. Discuss with the family
about the use of health
facilities.
Results :
DS : The family mentioned
the benefits of health
facilities for healing
sick family members.
DO : Families are able to
repeat the
information
submitted.
Acute pain Tuesd 1. Assess pain scale. Result : Wedn Subjective :
related to the ay Mrs. A said the pain scale esday - Mrs. A said that the pain was
inability of the 29/5/18 was 4 (moderate pain). 30/5/18 slightly less than yesterday
family to care for 16.15 2. Observe vital signs. 16.25 (pain scale 3).
sick family Results : - Clients say they are able to
members. TD : 150/100. control pain with relaxation and
N : 90 x/m distraction techniques (clients
RR : 18 x/m do pain distraction techniques
S : 36.8 C by reading the Koran).
3. Advise pain management - The client mentions the cause
techniques (relaxation of the occurrence and the
techniques). pain.
- The client says the pain is
reduced after doing
 Results :
Mrs. A demonstrates
relaxation techniques.
4. Encourage the client to
perform pain management
techniques (distraction)
according to the client's
habits.
Results: the client said he
did a distraction technique
by reading the holy book
Al-Quran.
5. Advise the client and
family warm compresses
on the back of the head.
Results: Clients and
families are cooperative.
6. Encourage the client to
increase rest. Results :
DS : The client said he
understood the
instructions given.
DO : Cooperative client.
Seemed to listen
carefully to the
instructions given.
taught pain management
techniques.
- The client said he felt more
comfortable and the pain was
reduced after doing a warm
compress on the back of the
head.
Objective :
- Mrs. A was able to demonstrate
relaxation techniques,
distraction and warm
compresses on the back of the
head.
- Mrs. A no longer looked
restless and grimaced.
- Vital signs : BP :
140/90.
N : 84 x/m
RR : 18 x/m
S : 37 C
A : Problem partially resolved
Planning :
- Assess pain scale
- TTV Observation
- Recommend relaxation
techniques.
- Suggest doing distraction
techniques.

Knowledge Tuesd 1. Assess the knowledge of
deficiency related ay clients and families about
to the inability of 29/5/18 hypertension.
the family to 16.25 Results :
recognize the DS : client and family
problem mention about
hypertension in their
own language.
DO : The client and
family are able to
mention about
hypertension but they
often forget and are
not fluent.
2. Discuss with the family
about hypertension by
using leaflets covering the
understanding of
hypertension, its causes,
signs and symptoms,
disease process,
complications, treatment
and prevention of
hypertension.
DS : The family said they
were willing to listen to
the information.
- Recommend giving a warm
compress on the back of the
head.
- Instruct client to increase
rest.
Wedn Subjective :
esday - The family said they
30/5/18 understood the disease,
16.35 condition, and treatment
program given to Mrs. A.
- The family mentions the
meaning of hypertension, its
causes, signs and symptoms,
complications, treatment and
prevention of hypertension in
their own language.
Objective :
- Clients and families are able
to re-explain what was
explained but still often forget
and are not fluent.
- Clients and families know the
complications of hypertension
A : Problem partially resolved.
Planning :
- assess family knowledge
about hypertension.
- Discuss with family about
hypertension with
 DO: Cooperative family.
3. Discuss with the family how
to care for (medication
program) sick family
members.
DS : The family said that
they carried out the
treatment program as
described by the nurse.
DO: Cooperative family.
Acute pain Wedn 1. Assess pain scale. Result :
related to the esday Mrs. A said the pain scale
inability of the 30/5/18 was 3 (mild pain).
family to care for 16.45 2. Observe vital signs.
sick family Results :
members. TD : 140/90.
N : 84 x/m
RR : 18 x/m
S : 37 C
3. Advise pain management
techniques (relaxation
techniques).
Results :
Mrs. A demonstrates
relaxation techniques.
using leaflets covering the
understanding of hypertension,
causes, signs and symptoms,
disease processes,
complications, treatment and
prevention of hypertension.
- Discuss with family method care
for sick family members.
Thursd Subjective :
ay - The client says the pain is no
31/5/18 longer felt.
16.10 - The client said he was able to
control pain with pain
management techniques.
- The client says the pain is
reduced with pain
management.
- The client said that he felt
comfortable because the pain he
felt had disappeared.
Objective :
- The client states a sense of
comfort after the pain subsides.
- The client is able to
demonstrate relaxation,
distraction and compression
techniques
4. Encourage the client to
perform pain management
techniques (distraction)
according to the client's
habits.
Results: the client said he
did a distraction technique
by reading the holy book
Al-Quran.
5. Advise the client and
family warm compresses
on the back of the head.
Results: Clients and
families are cooperative.
6. Encourage the client to
increase rest. Results :
DS : The client said he
understood the
instructions given.
DO : Cooperative client.
Seemed to listen
carefully to the
instructions given.
warm on the back of the
head.
- The client is able to state
the cause of the pain.
- Mrs. A did not look agitated
and grimaced.
- Vital signs : BP :
130/90.
N : 78 x/m
RR : 18 x/m
S : 36.6 C
A : The issue is resolved
Planning :
The intervention is maintained by
the client and family.
Knowledge Wedn 1. Assess the knowledge of Thursd Subjective :
deficiency esday clients and families about ay - The family said they
related to the 30/5/18 hypertension. 31/5/18 understood the disease,
inability of the 16.55 Results : 16.20 condition, and treatment
family to DS : client and family program given to Mrs. A.
recognize the mention about - The family said that they
problem. hypertension in their carried out the treatment
own language. program according to the
DO : The client and family nurse's description.
are able to mention - The family mentions the
about hypertension even meaning of hypertension, its
though they often causes, signs and symptoms,
forget. treatment and prevention of
2. Discuss with the family hypertension in their own
about hypertension by language.
using leaflets covering the - Client and family mention
understanding of complications of hypertension
hypertension, its causes, Objective :
signs and symptoms, - The client and family are
disease process, able to carry out the
complications, treatment procedures described
and prevention of correctly.
hypertension. - Clients and families are able
DS : The family said they to explain again what the
were willing to listen to nurse explained about
the information. hypertension.
DO: Cooperative family. - Clients and families know the
3. Discuss with family complications of hypertension
how to care A : The issue is resolved.
(treatment program) sick Planning : The intervention is
family members. maintained by the family.
DS : The family said that
they carried out the
treatment program as
described by the nurse.
DO: Cooperative family.