CASE REPORT

OF NURSING CARE WITH

“HYPOGLYCHEMIC”

DISEASE COMPLETED BY REGINA APRILIA HADI(20334093)

FORGIVES LECTURER
Ns. Milya Novera.MNS

DIII NURSING PROGRAM

FACULTY OF PSYCHOLOGY & HEALTH
UNIVERSITY OF PADANG STATE UNIVERSITY
  ASSESSMENT

A. BIOGRAPHIC DATA 3.Education:High School

1.Patient name:Mr.p 4.Occupation: housewife
2.Place/date of birth: langsa, 05- 5.Relationship with patient: wife
10-1988
3.Marital status: married
4.Religion: Islam
5.Ethnicity: Minang
6.Language spoken: Indonesian
7.Last education: High school
8.Occupation: farmer
9.Home Address: Padang

RESPONSIBLE BIO DATA

1.Name: Mrs. R 2.Age: 32
B. Reason for admission to the hospital: the patient was admitted on 11-09-
2022 from the clinic on the grounds that the body felt weak, decreased
appetite, dizziness, nausea

C. Health history:
1.The main complaint: the patient said, decreased appetite, shaking, nausea,
body felt weak
2.Current health history: during assessment the patient said nausea, fever,
and lack of appetite BP:130/70mmhg N:80x/min S:38.8 P:20x/min
3.Past medical history: the patient's family said the patient had been treated
before in the hospital and the patient had diabetes
4.Allergies: the patient says he does not have allergies
5.Drug habits: the patient has taken diabetes medication before
6.Smoking habits: the patient does not smoke
D. Daily habits

Habit Before getting sick After being sick

a.Nutrition 3x a day A 2x a day
Dietary habit portion is out The portion doesn't
Meal portion 1 serving run out
Frequency There isn't any portion
Eating problems 5 glasses a day There isn't any
Number of meals There isn't any 3 glasses a day
Drink amount There isn't any
Allergy

B. Rest / sleep 20.00 22.00

bedtime Wake up 06.00 05.00
time Sleep problems There isnt’any There isnt’any
C. CHAPTER 2x a day Rarely
Elimination Typical typical
Frequency Chocolate Chocolate
Smell Congested solid liquid
Color There isn't any There isn't any
Consistency
Chapter problem

D. BAK Frequency Seldom Seldom

Frequency Typical Typical
Smell Yellow Yellow
Color There isn't any There isn't any
Bak problem

E. Activities Working There isn't any

Daily There isn't any There isn't any
Spare time

F.Personal hygine 2x a day Seldom

Bath
Soap allergy There isn't any There isn’t any

Hair washing
Frequency 2x a day Seldom

Nail hygiene Seldom

Frequency 1x a week

Oral hygiene
Tooth Teeth look good Teeth are a bit yellow
Tongue Normal Normal
Oral mucosa Pink Pale pink
G. Psychological, social, and spiritual
data
1.Psychological data: the patient's
soul seems fine
2.Social data: patients can answer
questions well
3. Spiritual data: during illness the
patient cannot carry out his worship

H. Physical examination
1.General appearance
a.Level of consciousness: normal
Height: 167 cm Weight:54cm

2. Vital signs
a.Blood pressure: 137/80mmhg
b. Pulse: 83x/min c.temperature:28,8
d.breathing:24x/min
3.Head b.Olfactory function: normal
a.structure: symmetrical head c.Mucous membrane: normal
b.hair: neat black hair d. bleeding: none
c. Scalp: scalp looks clean e.complaint:none
d. face: face treads lethargic
e. complaint: none 6.Ears
a.structure:normal
4.Eyes b. function: good
a.Sharpness: normal b.schelera:white c.cerumen: good
c.pupil:normal d. Ear fluid: normal
d. conjunctiva: pink e. complaint: none
e. Eyeball movement: normal
f. Auxiliary tools: none
g. complaint: none

5.Nose
a.structure: pug
7. Mouth, teeth, tongue Shape: normal symmetric
a.Lip condition: pale red Lungs
b. Gum condition: good Inspection: normal
c. State of the tongue: good breathing rhythm
d. The condition of the teeth: neat Palpation: no tenderness
e.Speech ability: good
f. Chewing function: good Heart
g. esophagus: normal i: no enlargement of the heart
h.sound:normal P: no pain
i.complaint:none P: normal heart shape
A: no munmur
8.Neck Complaint: none
a.Thyroid gland: none
b. Jugular pen: none
c.Lymph nodes: none
d. Complaint: none
9.Chest
10.Abdomen
i: the abdominal wall is not swollen
A: no tenderness and mass
P: there is a tympanic sound
P: normal bowel sounds are heard
Complaint: none

11.Genitalia
There is no tenderness, no abnormalities, and no catheter is attached

12.Esteremity
a.top: no edema, no tenderness, symmetrical
b. bottom: left and right leg symmetrical, no wound abnormalities
I.Diagnostic check
Laboratory
Routine blood
check HB:11.6
Leukocytes:18,500
Erythrocyte:4.57
Platelet:405,000
HT:37

Clinical chemistry
2 hours pp: 95
Urea:38
Creatinine:2.4
Sodium:131
Potassium:4.9
Chloride:104
J.Medical treatment program
 Ivfd futrolit / 8 hours drip ondansentron 1 amp
 Omz 1x1
 Sucralfate 3x1
 Dyspflalite 3x1
 Cefraxon 2x1
 urine check
 skintes

DS: the patient says that his appetite is reduced, he has difficulty eating,
coughs, fever, a little shortness of breath
DO: the patient looks weak The meal portion is not finished The patient
appears to be sleep deprived
Thank you