keperawatan keluarga-inggris version
TRANSCRIPT
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ASUHAN KEPERAWATAN
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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
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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
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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
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= 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
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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
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- 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
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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
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about the causes of uric acid
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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
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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
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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
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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.
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- 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
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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.
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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
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