ARRANGED BY :

Dhian Aji Candra 1614201110071

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
Look
I. Upper limb
Brownish and dense skin color, dry skin, no edema in
the right and left palms, no fractures and deformities.
II. Lower limb
Brownish skin color, swollen on the back of the right
and left foot, no fracture and deformity.
Feel
I. Upper limb
There is no tenderness in the right and left upper
extremities, no numbness, no tingling.
II. 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.
Move
I. 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.
II. 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.
Data Analysis
NURSING
DATA ETIOLOGY
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 : Risk for
- Swelling on the right and left back. ineffective
Diabetes Mellitus
peripheral tissue
A. Vital signs perfusion
Blood pressure : 120/80 mmHg
Pulse : 88x / minute
Respiratory : 18x / minute
Temperature : 37,5°C
Intervention
Nursing
No Nursing Care Plan
Diagnosis
1. Risk for Outcome Intervention Rasional
ineffective NOC : NIC :
peripheral tissue
 Tissue perfusion :  Observe the  To find out the
perfusion
cerebral. presence of area is
GOAL :
certain areas that sensitive to
 After nursing for 2
are only heat / cold /
x 24 hours there is
no disruption in sensitive to heat sharp / blunt.
the patient / cold / sharp /
circulation status. blunt.
CRITERIA :  Monitor for  To find out
 Systole and thromboplebitis inflammation
diastole pressure and pain.
within the
expected range.
 Collaboration of  To reduce pain
 There is no
ortostatik giving analgesic
hipotensi.
 Implementasi
Nursing Evaluation of Nurse’
No Day / Date Time Implementasi
Diagnosis Action s Sign
1 Thursday / 08.00 Risk for Observing the  S : Patient say
6th – ineffective presence of certain that there are still
December 08.10 peripheral areas that are only areas that are
2018 tissue sensitive to heat / only sensitive to
perfusion
cold / sharp / blunt heat / cold / sharp
/ blunt.
 O : The patient
feel no pain when
pinched on the
peripheral side.
 A : The problem
has not been
resolved.
 P : Intervention
continued.
 Nursing Evaluation of Nurse’s
No Day / Date Time Implementasi
Diagnosis Action Sign
2 Thursday / 09.00 Risk for Monitoring for  S : The patient
6th – ineffective thromboplebitis said there was no
December 09.10 peripheral swelling, redness,
2018 tissue and pain in the
perfusion
leg and arm.
 O : No swelling,
redness, and pain
in the patient leg
and arm.
 A : The issie is
resolved.
 P : Intervention
continued.
 Nursing Evaluation of Nurse’s
No Day / Date Time Implementasi
Diagnosis Action Sign
3 Thursday / 6th 10.10 Risk for Collaborate to  S : The patient
December – ineffective provide analgesic said felt no
2018 10.20 peripheral pain.
tissue  O : The patient
perfusion
does not feel
pain when
palpated.
 A : The issue is
resolved.
 P : Intervention
completed.
 Evaluation
Nursing
No Day / Date Time Evaluation
Diagnosis
1 Tuesday / 08.00 Risk for  S : The patient said that there was no
11th – ineffective longer an area that was only sensitive
December 08.20 peripheral tissue
perfusion
to heat / cold / sharp / blunt / and the
2018
patient also said there was no swelling,
redness, and pain in the leg, arm and
other parts of the body.
 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
THANK YOU