Keperawatan Keluarga-Inggris Version

7/30/2019 Keperawatan Keluarga-Inggris Version

1/13

ASUHAN KEPERAWATAN

D

I

S

U

S

U


2/13

ASSESSMENT

FOCUS DATA

a. Subjective Data- The client said that the client feels so tired

- The client said that 2 months ago she gets hyperglycemia

-

The client said that her blood glucose is 154 mg/dl

- The client said that the client get medicine from public health center

- The client said that the client did not know about her diseases/high blood glucose

- The client also said that she doesnt know the etiology from high blood glucose

- The client said that her medicine was empty

-

The client said that she feels better than before and never control in public health

service

- The client said that her legs sometimes feels distention

- The client said that her legs feels tingling

- The client said that her legs sometimes feel numbness

The client said that the client doesnt kno the asam rat


3/13

= 55/(2,46)

= 22,35- IBW = (TB-100)-10% (TB-100)

= (157-100)-10% (157-100)

= 57-5,7

= 51,3 kg

- Uric acidvalue is 9,6 mg/dl

- Blood Pressure 110/ 70 mmHg

- Respiratory Rate 24x/menit

- Pulse 80x/menit

- Temperature 36,6o

celcius


4/13

ANALISA DATA

NO DATA FOKUS MASALAH ETIOLOGY

1. Data Subjektif :

- The client said that feels tired

- The client said that 2 months ago the

blood glucose of the client was

increase.

- The client said the blood glucose of

the client is 154 mg/dl

- The client said that the client gets

drug from the public heart cervice

- The client said that the client said that

the client does not know about her

disease (high blood glucose or

diabetes mellitus)

- The client does not know what is the

Knowledge deficit

about her disease

diabetes mellitus or

hight blood glucose in

Mr. M family

especially Mrs. J

Lack of information about

her disease in Mr. M

especially Mrs. J


5/13

- Based on the laboratory diagnostic

result that the value blood glucose ofthe client is 154mg/dl since 2 months

ago

- Body height = 157 cm

- Body weight before illness = 50,5 kg

-

Body weight after illness = 55 kg- BMI = BB/ (TB)

2

= 55/(2,46)

= 22,35

- IBW = (TB-100)-10% (TB-100)

= (157-100)-10% (157-100)= 57-5,7

= 51,3 kg

- Blood Pressure 110/ 70 mmHg

- Respiratory rate 24x/menit

- Pulse 80x/menit


6/13

about the causes of uric acid

-

The client said that when the paincomes the client only give the

massage oil (minyak kayu putih,

balsam, minyak kelapa atau minyak

urut)

Objective Data :

- General condition of client looks

good

- The client 47 years old

- The client looks hold her legs which

one she feels pain

- The client also looks massage her

legs which one she feels pain

- The client does not know about uric

acid


7/13

FORM

THE PRIORITY OF NURSING DIAGNOSE IN FAMILY

Name : Mrs. J Age : 47 years old Problem : Diabetes Mellitus

NO CRITERIA PROFOUND SCORE JUSTIFICATION

1. The characteristic of

the problem

Actual = 3

Risk = 2

Potential =1

1 3/3 x 1 =

1

The characteristic of health problem

is actual because when the student

collage doing assessment her blood

glucose is high than before 154

mg/dl (normally = 110-140 mg/dl)

2. Possible the problem

for changing :

Easy = 2

Partial = 1

Difficult = 0

2 x 2 =

1

Based on Mrs. J problems that

looking difficult for changing

because the clients family said that

it difficult if change the eat pattern.

3. Potential prevent the

bl

1 2/3 x 1 =

2/3

The potential for disease prevention

b th bl i b i


8/13

FORMAT

THE PRIORITY OF NURSING DIAGNOSE IN FAMILY

Name : Mrs. J Age : 47 years old Problem : Uric acid

NO CRITERIA PROFOUND SCORE JUSTIFICATION

1. The characteristic of the

problem

Actual = 3

Risk = 2

Potential =1

1 3/3 x 1 =

1

The characteristic of health

problem is actual because when I

assess her health problem, she

feels pain on her joint. Based on

the result of uric acid diagnostic

test, the clients score is 9,6 mg/dl

while the normal value of uric

acid for women is 2,66 mg/dl.

2. Possible the problem for

changing :

Easy = 2

P ti l 1

2 x 2 = 1 Mrs. Js problem is said to be

changed partly because the family

does not know how to solve the

h lth bl th t


9/13

PLANNING OF NURSING CARE with Mr. M ESPECIALLY Mrs. J

NO NURSING DX.GOAL NURSING

INTERVENTION

EVALUATION

GENERAL SPECIFIC CRITERIA STANDAR

1. Lack of knowledge

about diabetes mellitus/

high blood glucose in

Mr. Ms family

especially Mrs. J.

After doing health

promotion, the

client and her family

are expected that

can understand

about diabetes

mellitus.

- Mention the

understanding the

definition of

diabetes mellitus

- Mention the

etiology of

diabetes mellitus

- Mention sign and

synmptom of

diabetes mellitus

- Mention the

complication of

diabetes mellitus

- Mention the

preventive of

diabetes mellitus

d

1. Make trash with

the client and her

family

2. Assess the client

identity and

condition

3. Assess the physical

examination

4. Give health

promotion/

education about

the diabetes

mellitus

Respond verbal 1. Client can mention

the definition of

diabetes mellitus.

2. Client can mention

the etiology of

diabetes mellitus

3. The client can

mention the sign

and synmptoms of

diabetes mellitus

4. The client can

mention the

complication of

diabetes mellitus.


10/13

- Mention

traditional

treatment of

diabetes mellitus.

5. The client can

mention the

prevention of

diabetes mellitus

6. The client can

mention the

traditional treatment

of diabetes mellitus.

2. Lack of knowledge

about uric acid in Mr.

Ms family especially

Mrs. J.

After doing health

promotion, the client

and her family will be

expected for

understanding about

uric acid.

- Mention the

definition of uric

acid

- Mention the

etiology of uric

acid

- Mention of sign

and synmptom of

uric acid

- Mention healthy

1. Make trash with

the client and her

family

2. Assess the client

identity and

condition.

3. Assess the physical

assessment

4. Give health the

education about

Respond verbal 1. The client can

mentiom the

definition about uric

acid

2. The client can

mention the etiologi

of uric acid

3. The client can

mention sign and

synmptom of uric


11/13

food and non

healthy food for

the client with

uric acid

- Mention the

healthy food and

non healthy food

for the patient

with uric acid.

- Mention the

traditional

treatment for uric

acid.

uric acid acid

4. The client can

mention the healthy

food and non

healthy food for the

clien with uric acid

5. The client can

mention the

traditional treatment

for client with uric

acid.


12/13

IMPLEMENTATION OF NURSING CARE with Mr. M ESPECIALLY Mrs. J

DATE TIME DX. NO IMPLEMENTATION AND RESPOND SIGNATURE

November,

24th

2012

18.00 1,2 - Making trash with client and her family

R/

S :

- The client said about her name

- The client introduce her family

- The client said about her family history

- The client said that


13/13

Keperawatan Keluarga-Inggris Version

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