Family Nursing Care Report of Mr.

N Family With Medical Diagnosis Hypertension

FAMILY ASSESSMENT I. GENERAL DATA The Head of Family The Head of Family address : Mr.N : Jl.Nakula Raya RT.23 Komp. Bumi pemurus permai The Head of Family Age The Head of Family Education The Head of family Occupation a. Members of family : N Name o 1 Mr.N 2 Mrs.S Age Sex Education Occupation Relationship to the head master Husband Wife : 56 years old : bachelor of education : Teacher

58 55

Male Female

S1 S1

Teacher Civil Servant

b.Genogram

Explanation : : Male : Female : Passed Away 3 : client : married : Diforce Disease : 1 : Hypertension -------- : living together

c. Type of Family : Type of family is Nuclear family because family consisted by 2 members in their house father and mother because his son doesnt stay in their house anymore because he is studying in java. d. Religion : Islam

e. Ethnic background : Banjarese

f. Socio-economic : Family income is from both of husband and wife , Mr.Ns salary is about Rp. 3.000.000/month , and Mrs.ss salary is about Rp. 2.500.000/month. Every month they sent money for his son who has study in java is about 2.500.000/month

g. Activities and recreation of family:

They work 6 days in a week from morning until noon . They usualy going to java to visite their son in holiday.

II.

HISTORY OF FAMILY DEVELOPMENT a. family development stage : stage of middle age family because their one and only son already left the house for is studying in java

b. Problem of Family development : There are no stage of development that are not fulfilled

c. Health Status of Each Family Member : Mr.N :suffering hypertension Mrs.S : has no health problem

d. Medical and Nursing History of Family Member : Mr.N said that he has genetic disease which is hypertension , because Mr.Ns mother and old brother also had hypertension and suffered stroke but now they are already passed away . Mr.N also had ever admitted to the hospital because high Cholesterol and hypertension 8 monts ago and hospitalized for 4 days. And for Mrs.S she had never get severe disease , she only get mild disease such as : influenza , cough, diarrhea. e. History of previous family : Mr.N is a second child of his family , his old brother is already passed away because of stroke and his sister still alive . Mrs.S is first child of her family she has a brother and he still alive.

III.

HOUSE AND ENVIRONMENT a. Housing :

lands area 15m x 10m and houses area is 12m x 8 m consist of 3 bedrooms, they are : main room (parents room) , Mr.Ns son room and guest room . 2 bathrooms , 1 living room , 1 family room , kitchen and terrace. Each room has window and ventilation except bathroom just only has ventilation. So, the air circulation is good enough. The floor is ceramics so it makes the floor looked clean , familys water supply source is from PDAM , disposal type use septic tank that located under their house. House Design :

b. Kind of neighborhood and activities : Mr.N neighboring with some civil servant family and also mercant family , all Mr.N neighbours are moeslem , and derived from several different provinces .

c. Transportation facilities : Mr.N familys transportation facilities is motorcycle they have 2 motorcycles one for Mr.N and one for Mrs.S d. Social activities/communication : Mr.N family classified as active family , they ussually participate in socialevent and working together in their neighborhood. e. Social and health facilities : There is health care centre about 1 km from Mr.N neighborhood

IV.

STRUCTURE OF FAMILY a. Interaction pattern among family member/communication : Mr.N family has openly interaction. So , between Mr.N and Mrs.S can give advive to each other , Mr.N and Mrs.S have a harmonious family , they often call his son who is studying in java to know his condition.

b. Domain family member in term of decision making : Mr.N c. Role of family (formal and nonformal) 1) Mr. N a) Role of formal : As a teacher : giving an education to his students , as a head of family : fulfill his household need. b) Role of nonformal : as an adviser to his family , as a protector for his family. 2) Mrs. S a) Role of Formal : as a civil servant , As a Wife and Mother b) Role of nonformal : as a place to share for her husband and son , as a household economic regulator . d. Value and norm of family : They actually dont have any specific norm and value, just common norm and value like respect older people , helping each other , loving each other

V.

FUNCTION OF FAMILY a. Function of affective : Mr.N and Mr.S respect each other in family even sometimes conflict happened between them because simple things but they resolve it soon.

b. Fuction of Social : they are moeslem. so , they are active in spiritual activity , eventough they dont have any specific organization.

c. Function of health care : 1) knowing about disease / health condition : Mr.N family is already could identificate their health promblem even just in commonly way

2) Making decision with respect to taking appropriate health action : they already can make a quick desicion to the health problem even sometimes Mrs.s still confused if ask something that against the intervention that already they made (salty food, highfat food). 3) Providing adequate nursing care to sick family member : they give the nursing care according to the planning they had made, but sometimes they dont do according to the planning. 4) Providing a home environment conducive to health mantenance and personal development : Mr.N had change some of his life style not entirely of it. 5) Utilizing community resources for health care : Mr.N sometimes go to the health care centre to check up his condition and get medicine (captopril and Ranitidine). d. Function of reproduction : Mrs.S is not following KB program anymore because she had got menopause and they cant have child anymore. 5. Function of economic : Mr.N economic condition is still stabil because the disease not really affecting their work

VI.

STRESS AND COPING OF FAMILY 1. Short and long term stressors 1) Short term stressors : client said that a few days ago his condition get a little worse , headache and dizzy oftenly occured. 2) Long term stressors : client said that he worried about his son who is still need much cost for his future 2. Family response to the situation or stressors 1) Short term stressors : client came to the health care centre to get check up of his condition

2) Long term stressors : client hope his son could through his college well and could be helpful later 3. Coping strategy : Mr.N and his wife always make a time to discuss if they have a problem 4. Disfunctional adaptation : they always could handle if there are some conflict and misunderstanding between them.

VII.

GENERAL CONDITION

Main complain : client said that sometimes he got dizzy and headache and everytime he check his blood pressure it is always high.

Vital Signs: BP : 160/100 mmHg R : 22 x/ min T : 36,2 C HR : 84 x/min

Antropometric Data: BW : 64 kg BH : 165 cm IBW : (BH-100) 10%(BH-100) : 656,5 : 58,5-71,5kg

1. Skin Clients skin general condition looked clean , clien complexion is brown , client skins moistness is moist , clients skin turgor is back in less than 1 second.

2. Head and Neck Clients head is symmetric , client scalp is clean , client hair distribution i s spread evenly , clients hair is black , clien had no edema or lesion in the head, clients neck is symmetric. Client said that sometimes he got headache and dizzy

3. Visual and eyes Clients visual function is not really good, client use a glassess if he want to read or teach , clients eyes are symmetric , clients conjuctiva is unanemic , clients had no edema and lesion on eyelids , clients sclera is white , clients pupil reflex is positive, clients cornea and lens are clear.

4. Smelling and Nose Clients smelling function is good, clients nose are symmetric , clients nose cavity is clean , there is no bleeding or inflammation of the nose , there is no obstuction in upper respiratory tract , client had no complain about smelling problem .

5. Hearing and Ears Clients hearing function is good characterized by client could hear the questions from the nurse and answer properly , clients ears are symmetric , clients ears cavity had minimal amount of serumen , there are no bleeding and inflammation of the ears, client had no complain about hearing problem , client didnt use any hearing aid.

6. Mouth and Teeth Clients mouth looked clean , clients chewing function and swallowing function are good , clients teeth is not complete , there is no inflammation and bleeding on the mouth, clients lips mocouse is moist.

7. Chest and Respiration Clients chest looked symmetric , clients chest expansion isnt symmetric , client didnt use auxilliary muscle breath , clients respiration is 22x/min , clients tactile fremitus is symmetric on both of side , clients chest percussion is deaf ,

clients breathing sound is wheezing , client had no complain about respiration problem .

8. Heart and Circulation Clients ictus cordis isnt visible , clients ictus cordis palpable on ICS 5 axilla sinistra , clients heart percussion on the right side from ICS 3-4 sounds deaf and on the left side from ICS 3-5 sounds deaf , clients heart auscultation sound is S1 and S2 reguler , clients fingertips and lips are pink, clients CRT is back in 1 second .

9. Abdomen I : Client abdomen looked symmetric , client looked use auxilliary muscle

breath, A : Clients bowel sound is 12 x / m P : Clients abdomen sounds hypertymphanic P : There is no edema in the abdomen, there is no pressure pain in the abdomen .

10. Genitalia and Reproduction Client elimination function is good , client had no complain about elimination problem , client had 1 son , client had no problem with reproduction system .

11. Upper and Lower Extremities Clients extremities are symmetric , clients extremities movement is normal , client could sit and walk , there is no trauma in client extremities , client had no limitation of motion , clients activity scale is 1 , clients muscle strength is 5555 5555 5555 5555 (5 : Normal movement against graviti with a full resistence) FAMILYS EXPECTATION Mr.N hope that his hypertension will get better and his headache wont occured often , and he hope that health care worker more care and give a health check to the community and do home visit. So , he shouldnt go far to check his condition.

VIII.

1. DATA ANALYSIS Hypertension on Mr.N No. Data 1. SD: Etiology The inability of the family in Mrs.S said that she still confused decision if Mr. N ask something that making of against the plan that they made family (want to eat salty food, Highfat members with hypertension food) OD: Vital Signs: Problem Decision making conflict of food

BP: 160/100 mmHg R: 22 x / min T: 36.2 Co HR: 84 x / min Data Antropometric

Client's BW: 64 kg Client's IBW: 58.5 to 71.5 kg

2.

Risk Factor: a. Lack of compliance regarding the management of Hypertension (blood pressure checks irregular). b. Mr.N dietary intake poorly controlled (sometimes still consume salty food andmeat). c. Less physical activity levels (Mr.N just resting at home).

The risk of stroke due to a family's inability to modify the home environment, especially related to the diet and physical activity

B. Scoring Before determining the priority issues in family care plan Mr. N score will first be made to determine priority health issues on Wednesday, November 27th, 2013 as follows: 1. Decision making conflict of food related to the inability in decision making for family member with hypertension. No Criteria 1. 2. 3. 4. Count Score 2/3 2 2/3 3 5/6

Nature of the 2/3x1 problem presented Modifiability of the 2/2x2 problem Preventive potential Salince Total score 2/3x1 1/2x1

2. The risk of stroke related to the inability to modify the environment. No Criteria 1. 2. 3. 4. Count Score 2/3 1 1/3 2 3/6

Nature of the 2/3x1 problem presented Modifiability of the 1/2x2 problem Preventive potential Salince Total score 1/3x1 1/2x1

Problem Priority 1. Decision making conflict of food related to the inability in decision making for family member with hypertension. 1. The risk of stroke related to the inability to modify the environment.

C. Nursing Intervention for Mr.N Family No Date Diagnosis Goal General Specific Intervention rational

1.

Thursday, November 28th, 2013

Decision decision making conflict of food related to the inability in decision making for family member with hypertensi on.

Having carried out the health promoti on to the family to be able in provide the proper planning that related to the hyperten sion to family member s who is sufferin g hyperten sion

Clients 1. Assess the 1. Client's and family's knowledg families knowledg e level can e of determine determi hypertensi the ne on interventi planning managem ons that to treat ent will be family carried member out who has 2. Assess the 2. Identify experien family's whether ced a ability to the family hyperten provide has given sion the a well through planning interventi diet, for Mr.N on activity, 3. Provide 3. Increase and an clients medicati explanatio selfons n of the awareness dangers of to not not against following the plans a plan that that have had been been set set 4. Teach 4. In order wife to for clients firm in willing to providing follow the appropriat plan that e has been treatment set plan for client. 5. Brief 5. Knowing evaluation the of the outcome explanatio of the ns that briefing. have been given

2.

Thursday, November 28th, 2013

The risk of stroke related to the inability of the family to modify house environme nt especially diet and physical activity

Having carried out the health promoti on to the family to be able to perform control to prevent the happeni ng of stroke

Clients and families can mention how to control blood pressure of family member s who have hyperten sion, a family can modifies the environ ment to do the preventi ve control of his stroke occurred (especia lly diet and physical activity) , the client and family could Identific ation the types of food and physical activity should be carried out.

1. Assess familys knowledg e about how to modifies environm ent for Mr. A

1. Identifyin g family knowledg e and actions that have been performed in an attempt to modify the family environm ent of the diseased of family member 2. Give him additional 2. Give informatio informatio n about n how to the treat implemen hypertensi tation of on on diet, new diet physical and aktivitaas exercise and activities symptoms of stroke

3. Encourag e clients to get to the health facility to check up his blood pressure regularly and if stroke symptoms occured

3. Prevent further deteriorati on if the alarm is found

4. Give the 4. Provide opportunit family an

opportunit y to determine the attitude to the next plan

ies to fatherly family determine s the choice of the health of his family members

5. Give praise to the Traffic and 5. Complime positive nts ideas improve expressed selfit in esteem addressin and g family motivatio disease n to follow up families

D. Implementation No. Date Thursday, 1. november 28th, 2013

Diagnosis Implementation decision 1. Assessing familys making conflict knowledge about of food related treatment of to the inability hypertension in decision making for 2. Assessing family's family member ability to provide a with well intervention to hypertension. Mr.N 3. Giving explanation of the dangers of not following a plan that has been set 4. Teaching clients wife to firm in providing appropriate treatment intervention.

sign

2.

Briefing evaluation of the explanations that have been given Thursday, The risk of 1. Assessing family November stroke Related knowledge about 28th, 2013 to the inability how to modify the to modify the environment to Mr. environment in N a family related to diet and 2. Providing counseling physical to families regarding activity the implementation of dietary restrictions, especially fatty foods, and high salt, increase the consumption of fruits and vegetables, as well as doing physical activity 3. suggesting clients to immediately admit to the health facility to check blood pressure and stroke if symptoms occured 4. Giving families the opportunity to take a stand for the next plan 5. Giving praise to the Traffic and positive ideas expressed it in addressing the family of disease recurrence

5.

E. Evaluasi No. Date Thursday, 1. November 28th, 2013

Diagnosis decision making conflict of food related to the inability in decision making for

Evaluation S: Mr.N and Mr.S said already able to determine a plan for overcoming the problem of hypertension and be more

family member assertive in implementing with hypertension A: Issues related to food decision conflicts with hypertension had been resolved P: Stop the Interventions The risk of S: stroke related to the inability Family said that they already know to modify the how prevent Mr. N increases in blood environment in pressure through diet and exercise a family related physical activity to diet and physical A: activity The risk of stroke is not happening P: Intervention to be continued by the family at home 1. Blood pressure control 2. Physical activity

3.

Thursday, november 28th, 2013