TREATMENT GIVEN TO MRS.

S PATIENT SUFFERING NUTRITIONOUS PROBLEM AT MELATI 1 ROOM

AT LOCAL HOSPITAL dr. LOEKMONO HADI KUDUS

A. REVIEW
Day/Date : Monday, July 1, 2019
Time : 14.15
By : Mrs. AM

1. PATIENT’S IDENTITY
a. Patient’s Identity
Name : Mr. S
Date of Birth : October 20, 1956
Sex : Female
Religion : Islam
Education : Primary School
Occupation : Entrepreneur
Race/Nationality : Javanese/Indonesian
Marital Status : Married
Address : Rejosari 05/03, Dawe, Kudus
Med Rec Number : 700XXX
Diagnosis Diabetes Mellitus

b. The Concerning Person’s Identity

Name : Mr. M
Date of Birth : April 15, 1950
Sex : Male
Religion : Islam
Education : Primary School
Address : Rejosari 05/03, Dawe, Kudus
Relationship to the patient : The husband

2. MEDICAL RECORD
a. Main Complaint
Feeling itchy
b. Heretofore medical record
The patient said she had felt itchy since before visiting the hospital and was begun by
vomiting. On June 25, 2019, the patient was sent off to Loekmono Hadi hospital,
Kudus. After arriving at ICU, she was treated by the concerning medical officer with
result TTV : TD : 190/110 mmHg, HR : 100 x/m RR : 20 x/m, T : 37.2, SpO2 : 99 and GDS
: 156 mg/dl. In the ICU, she was given a therapy through initial instruction of the
doctor and it was continued. Then, the medical diagnosis made them moved to be
inpatient in Melati 1 room.
c. Previous medical record
The patient admitted she ever suffered DM and HT
d. Family medical record
The patient’s family said not to have any medical record as suffered by the patient,
to suffer DM and HT.
e. Record of Diseases
 The patient admitted to not have any medical, dietary, air, and other allergies.

3. Functional pattern
a. anthropometry : Tb = 155 cm
bb = 50kg
lila = 24,1 cm (N = > 23,5 cm)
imt = BB (kg)/TB2 (m) = 50/1,552
= 20,8 (N = 18,7 – 23,8)
BB ideal = 47,8 kg
b. Bio-chemical : June 27, 2019. 16.00 – 16.33 Western Regional Time
hb = 11,9 g/dl
gds=124
Creatinine = 0,58 mg/ds (N=0,5-1,2)
Sodium = 132,2 (N=135-145)
Calcium= 3,61 (N= 3,5-5)
C. Clinical sign: the skin turgor returns quickly, normal mouth mucosa, moderate pale, and no edema
D. Dietary: soft dietary, 3 times a day, eat ½ - 1 portion

Remark Before feeling painful During feeling painful

Frequency 3 times a day 3 times a day
Types rice, side dishes, vegetables, sweet tea, and pure water Porridge, side dishes, vegetable, tea, and pure water
Portion 1 portion ½ - 1 portion
Drinking Pattern 10 glasses/day, pure water, and tea 6-7 glasses/day, pure water, tea, and milk
Weight 52kg 50kg
Complaint No itchy, nausea, vomiting, and loosing appetite
4. Physical check
a. General condition = seeming good
b. Consciousness = the patient was at compos mentis consciousness (fully conscious). GCS assessment (Glasglow Come Scale).
1. Eyes could open and see well. Scored 4.
2. Motoric was shown by having good movement.
3. Verbal was shown by clear and good vocal sounds.
C. Vital signs = Blood pressure 150/110 mmHg. Body temperature 36.7oC. HR : 70x/M. RR : 20x/M.
D. Height and Weight = before and after being sick (H 155 cm and W 52 Kg and after being sick the W was 50 kg).
F. Head and hair = shaped mesochepal, symmetric, no injury, no white hair, no crumpled, a bit dirty.
G. Face = No pale, symmetric, and no inflammation.
H. Eye = Asymmetric, Icteric Sclera, not anemic conjunctiva, no curving, no black eye bag.
I. Nose = Symmetric and no polyp
J. Mouth = not cyanosis mouth color, two broken teeth, dirty, wet lip, and no bleeding gum.
K. Ears = symmetric, a bit serumen
L. Neck = no enlarging thyroid
M. Chest = Lungs/Thorax -> I = symmetric, exhaling and inhaling normally, no chest retraction
P = Right and left vocal fremitus were equally strong and no pain, no inflammation
P = Sonor
A = Vesicular
Heart - > I = no ictus cordis
P = Palpable ictus cordis (ic 4-5), no pain on chest pressure, symmetric
P = Fading
A = Not heard, regular
Abdomen - > I = symmetric, no injury
A = Hypoactive colon noise
P = No palpable pain
P = Tympanic
Genital -> Not checked
Extremity - > Nail inspection : white, long, dirty, no edema
Functional ability: right 5.2, left 5.2. A) upper extremity = scale of muscular extremity upon sinistra and dextra
were respectively 5 indicated by ability to grab strongly, B) lower extremity = sinistra and dextra were 2 for each. Being unable to move
independently and needed support. Moving/walking by using wheel chair. C) On left hand, there was attached an infusion. No infectious
sign on the infusion penetration. No exaggerate pain while being penetrated by the infusion.

Nursing Diagnosis

Blood Glucose Level : Risk Of Instability Associated with Delays in

Cognitive Development
 Intervention

No Date DX NOC NIC Signature

1 Monday,July 1 After being conducted Nutrition Monitor

nursing actions along
1st 2019 3x8 hours,expect Weigh the patient
achieve blood glucose weight
rate : the risk of Teach diet recipe
instability can be
reduce by the target Teach patient’s the
outcome scale being name of foods that
maintain at level 2 to are in accordance
4: with recommend
diet.
230001 Blood Glucose
Treatment
230004 Glycocyte Management
Hemoglobin
Determine what
230007 Glucose Urine medication is
need,and administer
it according to a
prescription or
protokol

Increase familly
involvement

Encourage the
patient’s family
members to help in
developing a
nursing plan

Implementation

Monday, July 1, 2019

... 14.30 1. Nutrition monitoring

Subjective data: the patient said to voluntarily measure his weight.

Objective data: weight = 50 Kg

... 14.45 2. Improving family involvement

Subjective data: the patient family said to voluntarily assist in developing nursing plan.
Objective data: the patient family seemed voluntarily assist in developing nursing plan.

... 15.00 3. Teaching and issuing the dietary program

 Subjective data: the patient said to voluntarily be taught about dietary plan to consume.
Objective data: the patient was voluntarily taught

... 15.15 4. Curing management; metformin 500 mg

Subjective data: the patient said to voluntarily be given oral medicines included Metformin 500 mg.
Objective data: the patient drank the medicine voluntarily included Metformin 500 mg.

2. Tuesday, July 2, 2019

... 11.00 1. Monitoring nutrition

SD: the patient said to voluntarily measure his weight.

OD: weight = 50.2 Kg

... 11.15 2. Improving family involvement.

SD: the patient family voluntarily assisted in developing the further nursing plan.
OD: the family voluntarily assisted in the further plan.

... 11.20 3. Curing management; Metformin 500 mg

SD: the patient was voluntarily given oral medicine included Metformin 500 mg.
OD: the patient voluntarily drank oral medicine included Metformin 500 mg.

3. Wednesday, July 3, 2019

... 13.00 1. Monitoring nutrition

SD: the patient voluntarily measured his weight and checked his blood level/GDS
OD: weight = 50.7 Kg, GDS = 110

... 13.10 2. Teaching; preparing dietary plan

SD: the patient said to voluntarily be taught again about dietary plan
OD: the patient was voluntarily taught again about his dietary plan.

... 13.15 3. Medicine management; Oral medicine provision included Metformin 500 mg.

SD: the patient said to voluntarily be given oral medicine included Metformin 500 mg.
OD: the patient was voluntarily given oral medicine included Metformin 500 mg.

Evaluation

Number Date and Time Evaluation Signature

1 Monday, July 1, 2019. S : The patient told she was feeling

itchy all over her body.
15.30
O : The patient was crying since it
was painful. She seemed rubbing.
She looked pale. The nutrition
monitors were weight 50 = Kg, GDS =
124.

A : Nutrition problem had not been

overcome.
 P : Keeping the intervention by giving
analgesic.

2 Tuesday, July 2, 2019. S : The patient felt itchy on several

limbs (Chest and Hands).
11.35.
O : The patient seemed rubbing it.
The patient looked pale. Nutrition
monitors were weight 50.2 Kg.

A : Nutrition problem was partially

overcome.

P : Keeping the intervention by giving

analgesic.

3 Wednesday, July 3, S : The patient said her itchiness was

2019. decreasing.

13.20. O : The patient seemed calmer than

previous one. Nutrition monitors
were weight = 50.7 Kg, GDS = 110.

A : Nutrition problem was overcome.

P : Stopping the intervention.