NURSING REPORT Tn.

K
CARE OF PLAN PATIENT WITH DIABETES MELLITUS TYPE II
LESS THAN THE BODY IN MEDICAL DIAGNOSIS TYPE II DM
IN THE RSU DHARMA YADNYA AT THE BHARATA ROOM
JUNE, 10-13 2015
PATIENT ASSESSMENT
A. Identity
1. Patients Identity

2.

Name

: Tn.K

Age

: 49 years

Religion

: Hindu

Gender

: Male

Status

: Married

Education

: High School

Occupation

: Private

Ethnicity

: Indonesia

Address

: Jln. Daffodil no.46, Br. Kertajiwa, Kertelangu

Dates

: 5 June 2015

Assessment date

: 10 June 2015

Medical Records

: 12 83 79

Medical diagnosis

: diabetes mellitus type II

Responsible Person

Name

: Ny. S

Age

: 55 years

Relations with Patient

: Wife

Occupation

: tailors

Address: Jln. Daffodil no.46, Br. Kertajiwa, Kertalang

B. Health Status
1. Current Health Status
a. Main Complaint (during admission and now)
Patient said no appetite and swollen feet due to ulcers.
b. The reason for hospital admission and course of the disease at this time
Patient said drink a small water, no injury to the big toe on the right, there is pain on
the thumb of his right foot every night
c. Efforts are being made to overcome them
Patient Family said of that they brousht patient immedately to emergency room
dharma yadnya hospital .
2. Past Medical History
a. The disease has ever experienced
Patient said previously never suffered a serious illness and can be life threatening
b. Treatment
Patient say never treated previously
c. Allergies
Patient said that did not have a history of drug allergy or food allergy
d. The habit (smoking / coffee / alcohol, etc.)
Patient said that did not have the habit (smoking / coffee / alcohol)
3. Family Disease History
Patient he said to have diabetes hereditary disease inherited by his biological father
4. Medical Diagnosis and therapy
a. Medical Diagnosis: diabetes mellitus type II
b. Therapy
1) Infusion NaCl 20tpm
2) Cetofaxim 3x1gr
3) Insulin 3x4 1subkutan Sc
4) Metrodazole 2x500gram
C. The pattern of Basic Needs (Data Bio-psycho-socio-cultural-spiritual)

1. Pattern Perception and Health Management

a. Before illness
Patient said hard to keep his diet because of the demands of the job, if he felt sick he
would lay on the bed and never had treatment proper
b. During hospitalization
Patient are said to maintain cleanliness and health of themselves during hospitalized
and assisted families
2. Pattern-Metabolic Nutrition
a. Before the illness:
Patients said he ate 3 times a day with 1-out portion with a side dish: meat and
vegetables. and drink up 2 bottles of aqua responsibility. Body weight px: 75 kg
c. During hospitalization
Patient said eat 3 times a day with depleted half portion with a side dish: meat and
vegetables. Drink up 2 bottles of aqua responsibility. Body weight px: 70 kg

3. Pattern of Elimination
a. Fecal
1) Before the illness:
Patient said 1 times a day with a soft consistency, stool brown color and a
distinctive odor of feces
2) During hospitalization :
Patient said his current bowel 1 times a day with the consistency of soft and fatty,
brown color and a distinctive odor of feces
b. Urination
1) Before illness:
Patient said his urine normal yellow color with a distinctive smell of urine.
Number of 400cc whenever urinate move than 4-5 times daily.
2) During hospitalization:
Patient said urine no interference kunning yellow color, a distinctive smell of
urine, the amount of urine of 200 cc each time urinate 4-5 times daily.
4. Patterns of activity and exercise
a. Activity
Ability Care
Eating and
drinking

Showering
Toileting
Dressing
Moving

0:independent, 1: Tools, 2: assisted by others, 3: help other people and tools, 4: depend
totally

b. Exercise
1) Before the pain
Patient said before the illness can perform usual activities
2) During hospitalization
Patient said during hospitalization he can not perform usual activities
5. Cognitive Pattern and Perception
a. Cognitive: patient said he understand about his curret illness DM
b. Perception: patient said DM disease due to heredity
6. The concept of self-perception patterns
a. Patient identity : the patient said he accept his current condition
b. Patient role: the patient said he is a husband and father
c. Self ideal : patient said being able to know his true identity
d. Self-esteem: the patient said her life is very meaningful
7. Sleep and Rest Patterns
a. Before illness:
Patient said there is no interference with sleep patterns. Patients sleep less than 8
hours / day starting at 8:00 p.m. to 5:00.
b. During hospitalization :
Patient said the hospital was no disruption of sleep patterns, patients sleep less than 8
hours / day from 22.00 pm s / d 06:00 pm
8. Role-relationship patterns
a. Before illness
Patient said he had good communication wit his family, wife, brother .
b. During hospitalization
Patient said the hospitalization he communicate with children, wife and brother less
run smoothly because of very well
9. Sexual-Reproductive pattern

a. Before illness:
Patient said he is married and have children
b. During hospitalization :
Patient said the he has decrease his sexual desire
10. Stress Tolerance Pattern-Koping
Patient said if there is a problem usually tell the closest people like her
11. Pattern Value-Belief
a. Before illness
Patient said Hindu and usually pray at home every day. morning and afternoon, and
patients believe that illness is a medical disease (hereditary).
b. During hospitalization
Patients say Hindu and can pray on the bed
D. Physical Assessment
a. General condition: Good
b. The level of consciousness : komposmetis / apathy / somnolence / sopor / coma
GCS: Verbal: 5 Psychomotor: 6 .Mata: 4
c. Vital signs: pulse = 80 x / mnt, temperature = 36.5 C, BP = 100/80 mmHg, RR = 18
x / mnt
d. Physical status
1) Head:
a) There is no tenderness in the head
b) The shape of the eyebrows symmetrical, uniform distribution
c) The shape of the eye is symmetrical, anemia and unikterik
Neck:
a) No tenderness in the vein jungularis
b) No enlargement of the thyroid gland
c) No lesions on the neck
d) No jugular vein enlargement
2) Chest :
a) Lung
I : movement of the chest symmetrical, no lesions, no abnormalities the chest
P : there is no pain hit, tactile vocal premitus the symmetrical
P : hear sonor
A : hear tympani
b) Heart
I : ictus cordis to be seen on the ics 5, not there a lesion
P : ictus cordis palpable, there is no pain hit.
P : hear dullnes
A : s1 s2/ bj1 bj2 single reguler

3) Breast and armpit:

I = breasts symmetrical
P = no lumps
4) Abdomen:
I = no anxiety
A = noise bowel sounds 6-8x / mnt
P = no tenderness in 9 regions
P = hear timpany
5) Genitalia: not terkaji

6) Extremities:
Upper :
I = shape symmetrical hand termor no, no, cyanosis of the nail, inserted an IV in
his left hand, muscle strength normal
Lower :
I = symmetrical shape of the foot, no termor, the pdema, lesions on the legs and
swelling in the back of the right leg, muscle strength
There are injuries to the hand and toe.
7) Neurological: not an assessment

b. Supporting investigation
1. Laboratory data
Result
WBC
13.8
LYM
2.6

Flags
H

Unit
10 ^ 3/HL
10^ 3/HL

Expected value
3.8/10.6
1.0/4.4

MID
GRA
LYM%
MID%
GRA%
RBC
HGB
MCU
MCH
MCHC
RDW
PLT
MPV

1,3
9,9
18,7
9,7
71,6
3,53
11,9
105,7
33,7
31,9
12,6
249
7,0

10 ^ 3/HL
10 ^ 3/HL
%
%
%
10^6/HL
9/DL
FL
PG
9/DL
%
10^3/HL
FL

H
L
H
L
L
H
L

0.0/1,5
1,8/7,7
25,0/40,0
0,0/14,0
50,0/70.0
4.40/5.90
13.2/17.3
84.0/96.0
28.0/96.0
32.0/36.0
15.5/14.5
150/440
7.2/11.1

The results of clinical chemistry examination

Date /

Date / clock

clock
5/6/15
06.00
6/6/15
06.00
8/6/15
9/6/15
06.00

Examinatio

Results Unit

Value

Method

272

70-140

Mg/dl

PocT

235

70-140

Mg/dl

PocT

239

70-140

Mg/dl

PocT

202

70-140

Mg/dl

PocT

n
Blood glucose
Random
Blood glucose
Random
Blood glucose
Random
Blood glucose
Random

2. Radiological examination : 3. The results of the consultation

That the patient was examined by a doctor and get the diagnosis: cellulitis susp DM type II +
diabetic nicer grade III
4. Investigations of other diagnostic : -

E. DATA ANALYSIS
A. Tabel Analisa Data

DATA

ETIOLOGI

NURSING
PROBLEMS

(In accordance with

the pathophysiology)
DS = patient said appetite The unfulfilled needs of The
decreased from 3 days ago

the cell to O2

DO =

Decreased appetite

imbalance

in

nutrition less than body

requirements

- Patients weak
- Body weigh lost 5kg for Decreased food intake
3week
- Px can not finish
servings of food.

DS = DO = There appears to be a

Nutrition less than

body
requirements

Agent injury

Skin intergrity imparment

Wound

cut wound assesment

Damage to skin
integrity

Dehidration
DS = Px said he felt
weaknesess
DO = -

The body loses fluid

electrolyte
A decrease in
intracellular and
extracellular fluid
Faver
Increasing the body's

Intolerance activity

B. Tables List of Nursing Diagnosis / Priority Based Collaborative ProblemIntervension

N

Date /

hours were

Nursing diagnosis

Target

Ttd

found
1

11 june

The imbalance of nutrients the body

13 june

2015

needs b.d less than the decrease in the

2015

(...........)

intake d.d decreased appetite

2
11 june
2015

11 june
2015

Damage to skin integrity b.d agent wound

d.d injury on right thumb

activity intolerance b.d weakness d.d px

own difficult move.

(...........)
13 june
2015

13 june
2015

(
)

C. Intervantion
Nursing care of plan

No

Day /
date

Goals and criteria

Dx

results

Kamis,
1

11 juni
2015

Rational

After provide nursing care 1. Observe the diet of patients

1. to determine a patient's

given 3x24 hour nutritional

nutritional intake

needs are met with the

1

Intervention

2. Give the patient the nutritional

information 3. Instruct the patient 2 so in order the patient

criteria of the results:
would the importance of
1. The patient reported to eat little but often
nutrition for the body
increased appetite
4. Weigh the patient BB
2. Body weight increased
5. Schedule eating frequency of
3. To optimize the
gradually
patients with family
patient's meals
3.Px can spend one portion
of food

4. To know the BB

patients
5. For the patient that his

appetite is known and can

After provide a nursing 1. Provide information about
care

with

in

given

a wound treatment
2. Observe review patient wound
3x24hour patient wound is
a day
expected clean and dry
3. provide support and care
3

replace the corresponding

of food nutrients needed
with meal replacement
1. In order for the patient
to know the importance of
wound healing in the

After being given a x24hour nursing care for the

1. provides information about

motion activity and exercise
2. teach patients how to mobilize

patient is expected to be

and motion exercises

able to do motion activity 3. observation of motion activity
and exercise independently

and exercise patients

thumb of his right foot.

2. to determine the
condition

of

injured

patients
3. to assist wound healing
patients
1. that patients know the
importance

of

the

movement of a limb to
health
2. that patients know the
ways of doing motion
exercises for mobilization
3. to determine the
development of motion
activity
patients

and

exercise

D. Implementation
Hari/
Tgl/J
am

No

Nursing Action

Dx
1.

- Observe the patient's diet

- Encourage the patient to eat little
but often
- Helping patients eating schedule

Evaluation prosess

DS: patient says he is ready to

follow the advice given
DO: patients spend one serving of
food

2.

- Teach relaxation techniques to

3

patients
- Mengkolaborasi analgesic drugs

DS: Px says he is ready to

implement he advice given.

to patients

DO: The drug passes smoothly

- Provide information about the

DS: patient says he is ready to

injuries suffered by patients

implement the notified nurse

- Teach the patient ways of doing

DO: the patient looks nod

movement activities and exercises

3

- Taking action TTV

- Observe the condition of the
wound in a patient

DS: DO: BP: 120/80, N: 80x / mnt,

S: 36 C, RR: 20x / mnt

2

- Teach patients how to perform

DS: patient says he is ready to

the activity and motion exercises

implement the recommendation

that was told by nurses

- Observing the motion activity

and exercise patients

DO: -

- Provides information about the

DS: patient says willing to be

patient wound healing

willing to do therapy given

- Collaborate administration of

DO: Patients seem nod

analgesic drugs to patients

- The drug via IV entered smoothly

E. Evaluation
No

Day/Date
Time
1 Saturday ,

No Dx
1

13 june

Evaluation
S: Patients report increased
appetite

2015

O: Weight 75 kg, patients can

spend one portion of food
A: the issue is resolved
P: Keep track of nutritional intake

2 Saturday,
13 June
2015

TTd

px
S: patients say the wound is clean
and dry
O: patient wound dry, no pain, no

()

pus.
Saturday,

A: The problem is resolved

13 June

P: maintance the patient's

2015

condition
3
S: patients say capable of
movement and exercise activities
independently
O: A: The problem is resolved
P: Maintain motion activity and
exercise as well as the patient's
condition