PROBLEM WITH ANXIETY

Dwinka Puspa Wijaya

P17320319016
II A
Patient and Complaint Details

Patient Details
• Name : Mrs. E
• Gender : Female
• Age : 50 years old
• Medical Diagnosis : hypertension
• Ethnicity :Sundanese
Presenting Complaint

The patient was admitted to the hospital because

Mrs. E feel weak and woke up feeling numb, and
felt dizzy. Mrs. E complaints got worse since last
night before being admitted to hospital.
 Review Organ System

1. Head: 1. Neck : There is no swelling of

straight black hair color ,  clean ,  hair  the gland thyroid,no swelling of the
does not fall out , is jugular veins
not no lumps , no lesions. 2. Abdomen :
2. Eye : symmetrical , konjungtiva not symmetrical , no scarring former opera
anemic , sclera white , reflex to light. tion 
3. Nose : Clean ,  no expenditure of 3. Hands :  symmetrical , no edema,
blood or secretions , not exist polyps nails clean and short .
4. Mouth : not 4. Legs :
pale ,  mucous lips moist , not there cya symmetrical , no edema, no varicose
nosis , and does not exist thrush. veins.
5. Ear : Symmetrical, clean,   the
function of hearing good
Past Medical and Surgical History
2. Medication History
1. Social History
• The client said she did not
• Friends / closest people: The
consume herbs or drugs free
client says the person closest
medicine
to you is currently her
• The client says not to use
children
alcohol and drugs solve the
• Participation in groups: The
problem
client said she was involved in
recitation in the home
environment
• Barriers to dealing with
others: The client says no
have problems relating to
other people
. 3. Sexual History 4. Details from The Physical
Examination
The client is currently living
• Consciousness :
alone at home because all her
composmentis
children have a family.
• Blood Pressure: 150 /
However, often her children
100mmHg
visited her and chat or clients
• Pulse : 72x / minute
play with their grandchildren
• Respiration : 18x / minute
• Temperature: 36° c             
• Weight  : 75 Kg
• Height : 155 cm  
 PLAN
Implementation Evaluation

Data:
•The client's face looks tense
•The client looked cold sweaty
•The client's body looks fat
•Client feel worried about her
conditioncurrently
•The client feels dizzy and weak
Nursing diagnoses:
•Anxiety
•Sense of disruption
•Nutrient imbalance : more than the body's
needs
S:
•The client said that at this time she felt less
worried
•The client said she ate food from the hospital
and only snacked on fruit
•The client said sometimes they still feel
nervous when remembering the circumstances
•The client said she often broke out in cold
sweat
•The client said she was still comfortable with
the semifowler position
•The client said it would practice relaxation
techniques deep breath and technique 5 finger
hypnosis
 Implementation
Implementation :
•Foster a trusting relationship
•Assess the client's level of anxiety
•Review the techniqueused when feeling
anxious
•Teaches deep breath relaxation techniques
•Give a comfortable position
•Examine the causes of obesity
•Explain aboutthe importance of physical
activity
•Help clients choose the right food
Evaluation
O:
• The client's anxiety level is moderate to severe
•Clients are able to perform deep breath
relaxation techniques pretty well
•The client looks more comfortable with the
semifowler position
•The client is still visiblesweating
A:
•Anxiety problem has been partially resolved
•The problem of discomfort is partially resolved
•Imbalance problem nutrition more than the
body's needs have not been resolved
P:
•Practice deep breath relaxation techniques 3x /
day, after each breakfast, lunch and dinner
•Evaluate deep breath relaxation techniques
•Teach the 5 finger hypnotic distraction
technique
•Evaluation of diet
•Penkes about the right diet
•Evaluate a comfortable position