A.

Assessment
Assessment date : 5 December 2018
Room : Alamanda

1 Client Identity
Name : Ny. R
Age : 50 years old
Gender : Female
Address : Sungai Andai, Banjarmasin
Religion : Islam
Status : Married
Tribe / Nation : Banjar / Indonesia
Work : Private
Medical diagnosis : Diabetes Mellitus type II
Medical record : 18.11.59
Date of entry : 5 Desember 2018

2 Identity of the person in charge

Name : Tn. D
Gender : Male
Address : Sungai Andai, Banjarmasin
Relationship with client : Husband

3 The Main Complaint

The client says it often feels tingling and feels heavy to walk.

4 Current Disease History

The client said two days ago headache, it feels like being stabbed - stabbed. The client
says limp and if walking feels heavy. Feet often feel tingling. Then it was examined at
the community health center Sungai Miai, the GDS value was 411. From the health
center the client allowed to check in the hospital polyclinic. The client examined
himself at RSUD ULIN on 5 December 2018, the results obtained were GDS 298,
blood pressure 130/80 mmHg, pulse 88x / minute. Clients recommended for
hospitalization, the diagnosis is type II diabetes mellitus.

5 Past Medical History

The client underwent kidney stone surgery a year ago.

6 Family Disease History

The family has no history of diabetes mellitus, and other hereditary diseases.
7 Physical Examination
a. Vital Sign
5 December 2018
Blood pressure : 120/80 mmHg
Pulse : 88x / minute
Respiratory : 18x / minute
Temperature : 37,5°C
b. Skin
Brownish skin color, swelling in the right and left legs, dry skin, skin turgor in the
lower extremities is bad.
c. Head and Neck
 Head shape: mesochepal.
 Hair: gray hair, long, curly, thin, spread equivalent, no lesions.
 Eyes: symmetrical, non-jaundiced sclera, anemic conjunctiva palpebra is
not blackish, good vision.
 Ears: symmetrical, no abnormal output.
 Nose: no secretions, no lesions, no mass.
 Mouth: No thrush, dry lip mucosa, none bleeding gums.
 Neck: no enlargement of thyroid and lymph collection.
d. Lungs
Inspection : Symmetrical, chest development is not maximal.
Palpation : Symmetrical left and right lung development.
Percussion : Sonor.
Auscultation : No sound whezzing and ronkhi.
e. Abdomen
Inspection : No lesions, brown skin color.
Auscultation : Bowel sounds 10 x / minute.
Palpation : No mass, no lumps.
Percussion : Timpani.
f. Extremities
a. Look
a) Upper limb
Brownish and dense skin color, dry skin, no edema in the right and left
palms, no fractures and deformities.
b) Lower limb
Brownish skin color, swollen on the back of the right and left foot, no
fracture and deformity.
b. Feel
a) Upper limb
There is no tenderness in the right and left upper extremities, no
numbness, no tingling.
b) Lower limb
 There is pain in the right and left back of the foot, it feels painful and
suddenly suddenly feels like being electrocuted, sometimes it feels
tingling, the client says the scale of pain is 4, the frequency of pain is
often obtained.
c. Move
a) Upper limb
Right and left hands can be moved. The client's right and left hands are
able to break and hold, are able to carry out extensions, pronasi-supinasi,
and rotation.
b) Lower limb
Right and left feet can be moved. The right and left legs are able to release
and hold but are not optimal, unable to flex the extension, dorsiflexion-
plantarflection. There is swelling in the right and left back of the foot.

8 Functional Assessment
a. Perception of health-health management
The client said sick compilation was always checked into the health center
or doctor. The client says healthy is a condition of the body that can do
anything, while pain is a weak condition of the body. Clients do not drink
liquor, do not smoke, do not use drugs.
b. Oxygenation needs
The client does not have difficulty breathing, , no difficulty with cyanosis,
no coughing. No whezzing sounds, crackles.
c. Nutrition and Liquid Needs
Before being verified at the hospital the client said he ate 5 times a day,
his appetite increased since 1 month ago. Clients say they don't like
vegetables. Clients say they don't drink 6-7 glasses a day. Client body
height 155 cm, body weight 54 kg. The client said he gained weight for 1
month from 54 kg to 60 kg.When sick, the client gets a pulp of food
porridge without low sugar juice. When entering the BB client hospital it
drops to 58 kg.
d. Elimination Needs
Before entering the hospital, the client says that urine is eliminated ± 7-8
times a day, faecal elimination 2 times for ± 1 day (diarrhea) for 3 days.
When admitted to the hospital, elimination of urine frequency is slightly
reduced to 5-6 times a day, faecal elimination 1 time a day with soft
consistency.
e. Needs Rest and sleep
Before getting sick, the client's family said the client's sleep frequency
was 8 hours / day, with good sleep quality and no trouble sleeping
(insomnia, parasomnias). When entering the hospital, the client's sleep
frequency increases, ± the client sleeps around 10 hours / day.
f. Personal Hygiene Needs
 Before getting sick, clients always take a bath twice a day, diligently
brush their teeth, and toileting independently. Clients wash their hair once
in 2 days. When sick, clients can carry out self-care, such as bathing,
toilets, but in terms of client needs need help from others.
g. Recreational and Spiritual Needs
Before entering the hospital, clients say they like to take a walk to watch
television and gardening. Clients diligently pray 5 times. When entering
the hospital, clients can only pray.

B. Data Analysis

DATA ETIOLOGY NURSING DIAGNOSIS

DS :
- Clients say swelling in
the right and left back
of the foot.
- The client said he
already knew that the
client had DM disease.
DO :
- Swelling on the right Risk for ineffective
Diabetes Mellitus
and left back. peripheral tissue perfusion
A. Vital signs
Blood pressure :
120/80 mmHg
Pulse : 88x / minute
Respiratory : 18x /
minute
Temperature : 37,5°C

C. INTERVENTION
No Nursing Diagnosis Nursing Care Plan
1. Risk for ineffective Outcomes Intervention Rasional
peripheral tissue NOC : NIC :
perfusion  Tissue perfusion  Observe the  To find out
: cerebral. presence of the area is
GOAL : certain areas sensitive to
 After nursing that are only heat / cold /
for 2 x 24 hours sensitive to sharp /
there is no heat / cold / blunt.
disruption in the sharp / blunt.
patient  Monitor for  To find out
circulation thromboplebit inflammati
 status. is on and
CRITERIA : pain.
 Systole and
diastole  Collaboration  To reduce
pressure within of giving pain
the expected analgesic
range.
 There is no
ortostatik
hipotensi.

D. IMPLEMENTASI
Nursing Nurse’s
No Day / Date Time Implementasi Evaluation of Action
Diagnosis Sign
Thursday / 08.00 – Risk for Observing the  S : Patient say
6th 08.10 ineffective presence of that there are still
December peripheral certain areas that areas that are
2018 tissue are only only sensitive to
perfusion sensitive to heat heat / cold / sharp
/ cold / sharp / / blunt.
blunt  O : The patient
1. feel no pain when
pinched on the
peripheral side.
 A : The problem
has not been
resolved.
 P : Intervention
continued.
Thursday / 09.00 – Risk for Monitoring for  S : The patient
6th 09.10 ineffective thromboplebitis said there was no
December peripheral swelling, redness,
2018 tissue and pain in the
perfusion leg and arm.
 O : No swelling,
2. redness, and pain
in the patient leg
and arm.
 A : The issie is
resolved.
 P : Intervention
continued.
 3. Thursday / 10.10 – Risk for Collaborate to  S : The patient
6th 10.20 ineffective provide said felt no pain.
December peripheral analgesic  O : The patient
2018 tissue does not feel pain
perfusion when palpated.
 A : The issue is
resolved.
 P : Intervention
completed.

E. EVALUATION
No Day / Date Time Nursing Diagnosis Evaluation
Tuesday / 11th 08.00 Risk for ineffective  S : The patient said that there
December – peripheral tissue was no longer an area that was
2018 08.20 perfusion only sensitive to heat / cold /
sharp / blunt / and the patient
also said there was no swelling,
redness, and pain in the leg, arm
and other parts of the body.
1.  O : The patient feel pain when
peripheral pinched, there is no
swelling, redness and pain in the
patient leg and arm and the
patient does not feel pain when
palpated.
 A : There issue is resolved
 P : Intervention completed