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NURSING CARE OF MR.

JUSTIN

WITH DISORDERS OF THE ENDOCRINE SYSTEM

IN MEDICAL DIAGNOSIS DIABETIC MELITUS TYPE II

IN IRNA III RSUD GERUNG

MARCH 09-12-2018

I. NURSING STUDY
Date & Time of admission : March 05, 2018, 07.00 P.M
Room : IRNA III/ No. 7
Hospital : RSUD Gerung
Registration No. : 21 19 18
Assesment date & time : March 9, 2018
Medical Diagnosis : Diabetic Melitus type II

A. BIOGRAPHICAL
1. Patient
Name : Mr. Justin
Age : 62 years
Gender : Male
Religion : Cristian
Marital Status : Married
Education : Bachelor/Degree
Occupation : Teacher
Address : Mataram

2. Person in Charge
Name : Ms. Letty
Age : 57 years
Gender : Male
Religion : Cristtian
Marital Status : Married
Education : Bachelor/Degree
Occupation : Teacher
Address : Mataram
Relationship with Patient : Wife

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B. MEDICAL HISTORY
1. Chief Complaint
Calus diabetic on the right feet
2. Complaints when Assesment
Patient said that he dizzy, easily felt tired, and weakness
3. Present History Illness
Patient said thet he entered the hospital cause he felt dizzy and the calus is appear on
his right feet since 3 days ago and it can’t be recover. He has never taken away the
medicine before.
4. Past History Illness
Patient said that he had hypertension since 2 years ago
5. Family Health History
Patient said that before his mother has the same complaint as he did.

Genogram :

Symbols :

X : Died

: Male

: Female

: Patient

: Offspring Line

: Married Line

-------- : Living in the same house

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C. Physical Examination
1. General Condition : Compos Mentis
2. Vital Sign : BP : 170/90 mmHg
P : 86x / minute
T : 36𝑜 𝐶
RR : 20x/ minute
3. Antropometri
a. Weight before sick : 55 kg
b. Weight when getting sick : 46 kg
c. Height : 165 cm
𝑊 46 46
d. BMI : = = = 13,9
𝐻2 1,65 𝑥 1,65 3,3
4. Physical Examination
a. Head
Inspection : symmetrical shape, black hair, and no lesion
Palpation : there is no pain pressure
b. Eye
Inspection : symmetrical shape, there is no edema
Palpation : no pressure pain
c. Nose
Inspection : there is no secret and polyp
Palpation : no pressure pain
d. Mouth
Inspection : dry lips, dirty teeth, smelly mouth, and no lesion
Palpasiion : no pressure pain
e. Ear
Inspection : no cerumen, no hearing lost
Palpation : no pressure pain
f. Neck
Inspection : no edema, no enlargement of tyroid gland
Palpation : no pressure pain
g. Thorax
Inspection :no chest retraction and no lesion
Auscultasion : no wheezing and crackles, normal vesicular breathing
Palpation : no pressure pain
Percution : sonor
h. Abdomen
Inspection : no abnominal distention and no lesion
Auscultation : normal bowel sound
Palpation : no pressure pain
Percution : tympani

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i. Genetalia
Inspection : using urine chateter, urine production is about 100cc/day
j. Integument
Inspection : skin are brown and dried
Palpation : no pressure pain
k. Ekstremitas
 Upper
Inspection : symmetrical, no edema, using infusion on the right
hand
Palpation : no pressure pain
 Lower
Inspection : edema, ulcus diabetic
Palpation : there is pressure pain

D. Spiritual-Social-Psycological-Biological-History (Gordon Pattern)


1. Respiration
a. Before getting sick : patient said that he can breath normaly
b. When getting sick : patient said that he still breath normaly
2. Nutrition
a. Before getting sick : patient said that he eats 3 times a day in an adult
portion and drank 5 glasses of water a day, about
200 cc.
b. When getting sick : patient said only eat twice a day , two tablespoon
from the food that provided in hospital, cause he felt
nausea. Drink a glaas of water a day.
3. Elimination
a. Before getting sick : patient said that he can defecate and urinate normaly,
defecate once a day and urinate 3 times a day.
b. When getting sick : patient said that he never defecate since the wound is
appear and patient using catheter cause his feet is
hurt so he couldn’t walking to the toilet by himself
and need a urinate helper.
4. Sleep and Rest
a. Before getting sick : patient said that he spent for sleep about 7-8 hours a
day
b. When getting sick : patient said that his sleep is disturb because the pain
in his feet comes every 4 hours and the pain scale at
7.

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5. Activity
a. Before getting sick : patient said that he can do his daily activities, such
as gardening, helping his wife in the kitchen.
b. When getting sick : patient said that he couldn’t do anything. Because
his feet is hurt.
6. Spiritual
a. Before getting sick : patient said that he can go praying once a week in
chruch
b. When getting sick : patient said that he couldn,t go praying in church.
7. Relationship
a. Before getting sick : patient said that he had a good relationship with his
family, friend, and neighbors
b. When getting sick : patient said that he still maintance his relation with
others.
8. Self Concept
a. Before getting sick : patient said that he never be stress when he got a
problem, because he would discuss his problem with
family.
b. When getting sick : patient said that even he very stressed, he believe
that his wound gonna recover soon.
9. Cognitive
a. Before getting sick : patient said that everytime he got sick, he just need
to take bed rest for a while until he recover
b. When getting sick : patient said that he sould do diet for reducing his
blood sugar lever
10. Comfortable
a. Before getting sick : patient said that he always felt comfort
b. When getting sick : patient said that he never felt this uncomfort feeling
before. Scale of pain is 7, the pain is in his right feet,
the pain feels like stabbed feeling, the pain comes
every 4 hours.
11. Personal Hygine
a. Before getting sick : patient said that he showering 2 times a day
(morning & evening) and change the clothes
b. When getting sick : patient said that he never take showering since his
feet hurt

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E. Medicamtion (March 9, 2018)
Medication Dosage Route Function
Metronidazole 1 flash IV To prevent infection caused by
500 g line microorganism and anaerobic bacteria
Ketorolac 10 mg IV For non strict anti-inflammatory
line communing wed to relive inflammation and
pain
Ringer Laktat 20 tpm IV To restore body waterloss and nutrition
line

F. Data ABCD
a. Anthopometric
- Body weight before getting sick : 55 kg
- Body weight when getting sick : 46 kg
- Height : 165 cm
𝑊 46 46
- BMI : 𝐻 2 = 1,65 𝑥 1,65 = 3,3 = 13,9

b. Biochemistry
- Blood Sugar : 423 normal : 90 - 200
^
- Hemoglobin : 16,2 10 6/𝑚𝑐 normal : 13,00 – 17,3
c. Clinis
- Mouth : dry lips & dirty teeth
- Abdomen : normal bowel sound
- Integument : skin looks dry
- Extremity : there is pressure pain on right lower extremity
d. Diet
- Diet natrium
- Diet glucose
- And eating soft food

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II. NURSING DIAGNOSIS
A. ANALYZING
Name : Mr. M Registration No. : 21 19 18
Age : 62 years Room : IRNA II

NO SYMPTOM ETIOLOGY PROBLEM


1 Subjective : Idiopatic, age, and genetic Acute Pain
Client said that he feels the
pain on the right side of his Insulin deficiency
feet.
P : patient says the pain will Hypoglikemi
come when he sleeping
Q : patientsays that the pain Flexibilities of Red Blood
like stabbed feeling. It’s Cell
feel like someone is
hurting you by a knife. The woud is
R : the pain is in the right Loose of Oxygen
side of his feet.
T : patient says sometimes Acute Pain
the pain didn’t come

Objective :
- Patient look tired
- Skin is dried
- The wound size : 2 cm
- Characteristic of wound
: red, unthermal,
swollen, no pus, and
moist
- S : the pain scale is on 7
(severe pain) from 0-10
pain scale.
- VT :
~ BP : 140/90 mmHg
~ P : 86x/minute
~T : 36,3 %
~ R : 20x/minute
2. Subjective : Idiopatic, age, and genetic Imbalanced nutrition less
- Patient said that he than body needs
never feel hungry Reducing of pancreas cell
- Patient said that he feel
a nausea dan tired Insulin deficiency
- Patient said that he
eating twice a day, Catabolism of protein has

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2only finished two of
tablespoon of his meals incrase
that was provided by
the hospital. Weight has decrases
- Patient rarely drink
water. A glass a day. Risk of malnutrition
(about 200 cc)

Objective :
- Client look tired
- Dried of lips mucosa

ABCD Assessment :
A. Antropemetri
1. Weight before sick :
55 kg
2. Weight when got
sick : 46 kg
3. Height : 165 cm
4. BMI : 13,9
B. Biokimia
1. Hemoglobin : 16,2
10′6 /𝑚𝐿
2. Blood Sugar : 423
C. Clinis
1. Mouth : dry lips &
dirty teeth
2. Abdomen: normal
bowel sound
3. Integument : skin
looks dry
4. Extremity: there is
pressure pain on
right lower
extremity
5. Diet
1. Diet natrium
2. Diet glucose
3. And eating soft
food

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B. FORMULA OF PROBLEM

1. Acute pain related to the physical injury agent, as evidenced by the pain will come
when sleeping, the pain is in the right side of his feet, pain feels like stabbing feeling,
scale of pain is on 7 (severe pain).

2. Imbalanced nutrition less than body needs related to decrases of weight, as evidence
by patient said that he never get hungry, nausea, and tiredly, only eat the food which
is providing from hospital, drink a glass of water a day (200 cc), weight 55 to 46 kg,
height 165, intestinal noise 8x/minute, Hemoglobin : 16,2 10′6 /𝑚𝐿

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III. INTERVENTION
Name : Mr. M Registration No. : 21 19 18
Age : 62 years Room : IRNA II

A. Proroty Problem
1. Acute Pain
2. Imbalance nutrition less than body needs
DAY/D N PURPOSE INTERVENTION RESULTS CRITERIA
ATE O
Friday 1 after given intervention 1. Assess patient's pain 1. to find out the
09, for 2 x 24 hours, it is area of pain,
March expected that pain can be quality of pain,
2018 releasedcriteria: when pain is felt,
1. the patient said trigger factors of
pain was pain, the severity
reduced of pain that is felt
2. the patient's 2. assess the patient's 2. to find out if the
facial expression non-verbal patient really
was calm, not expression feels pain
grimacing in pain
3. pain scale 2 from 3. Assess the state of 3. to find out
(0-10) the wound whether there are
4. patients are able signs of infection
to do pain 4. to reduce pain
management 4. Teach patients deep
techniques breathing relaxation
5. vital signs are techniques
within normal 5. to reduce pain
limits 5. collaboration with
BP:120/90 medical teams in the
mmHg administration of IVs
P : 80x/ minute / drugs/alergic
T :36,5 0 C
2 RR : 20x/minute

After 2x24 hours of 1. Review patient 1. To find out


nursing action, the nutrition nutritional needs
patient’s nutritional needs
are achieved whith the 2. Assist patients in
2. Explain to patients
results criteria.
about the importance expanding know
- Increased
of nutrition ledgle of
appetite.
nutrition.
- The portions of
the patient’s meal
3. Assess the appetite 3. Find out if the
runs out. and the portion of
patient has
the patients meal.

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- Patient’s finished hospital
nutritional needs food.
are met. 4. Assess for nausea an 4. Find out how
- Moist lip mucusa vomiting many patients
- No nausea nausea vomiting.
vomiting

5. Recommend that the


5. Eat little food but
patient eat a little but
is often warm. often to make the
patient not
nauseous and
vomil.

6. Encourage the 6. To make it easier


patient to drink
to swallow food.
before eating.

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IV. IMPLEMENTATION
Name : Mr. M Registration No. : 21 19 18
Age : 62 years Room : IRNA II

DATE TIME IMPLEMENTATION RESULT SIGNATURE


Saturday, 08.00 1. Assessing the patient’s pain 1. P : abdominal pain during
10 March sleep
2018 Q : pain like being stabbed
R : pain is in the right side of
his back
S : pain scale 4
T : pain feels lost about 10
minute

2. Assessing the patien’s non 2. Patient’s looks grimaced in


verbal expression pain

3. Assessing the wound 3. Area of the wound 2 cm,


condition moist, no sign of infection

4. Teaching relaxing breathing 4. Patient be able to perform


techniques deep breathing relaxtion
techniques.

5. Observing Vital Sign 5. BP : 90/60 mmHg


P : 83x/minure
T : 36,50 𝐶
R : 20x/minute

6. Administering IV chateter 6. Patient is attached to 20


dpm RL infusion on the
right hand

7. Checking the nutrition 7. Patient says that he never


spent the food in hospital

8. Explaining the importance 8. Patient understand about the


nutrition importance of nutrition

9. Assessing the appetite and 9. Patient said that there’s no


eating portion appetite, half a meal.

10. Examineing the lips mucus 10. The lips mucus is dried

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12. Encourage patient to eat a 12. Patient want to eat a little
litte bit but often but oftenly

Monday, 14.00 1. Check the patient’s pain 1. Patient says that the pain
12 March was reduced
2018
2. Check the patien’s non 2. Patient looks relaxed
verbal expression

3. Check the wound condition 3. Wound length is about 2 cm,


the wound is dried

4. Teach relaxing breathing 4. Patient be able to do


techniques breathing relaxing
techniques
5. Observe Vital Sign
5. BP : 130/90 mmHg
P : 83 x/minute
T : 360 𝐶
R : 20 x/ minute
6. Infusion collaborate
6. Patient using RL infusion 20
dpm on the right hand
7. Checking the nutrition
7. Patient says that he never
finish out the food
8. Explain the importance
nutrition 8. Patient said that he
understand about the
importance of nutrision for
9. Assessing the appetite and body
eating portion
9. Patient can finish out his
10. Examine the lips mucus food

11. Assess the pretence of


nausea and vomiting 10. Undried of lips mucus

12. Encourage patient to eat a 11. Patient is not nausea and


litte bit but often vomit during eat the food

12. Patient would oftenly eat


the food with a small
portion

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V. EVALUATION
Name : Mr. M Registration No. : 21 19 18
Age : 62 years Room : IRNA II

DATE/TIME HOUR DX EVALUASI INITIALS

Tuesday ,13 march 14.00 1 S : Patient said pain was reducaded at 2 in pain scale
2018 P: Patient said pain will come when he sleeping
Q:Patient said the pain feels like stabbed
R:Patient said pain is in his right feet

O:
- Patient expression respon is relax
-Pain scale 2(0-10)
-Patient are able to do pain management
TTV : TD : 120/90 Mmhg
N : 80X/Mnt
S : 36,5
RR: 20X/Mnt

A : The problem is solved

P : Intervention is stopped

14.20 2 S :Patient reported an increase in his appetite


- Patient nutritional needs are met(eat 1
serving and drink 5 glasess a day and drink
one )
- The patient said there was no nausea
vomiting

O : -Moist lip mucosa


TTV : TD : 120/90 Mmhg
N : 80x/mnt
S : 36,5
RR: 20X/mnt

A : The problem is solved


P : Intervention is stopped

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ROLE PLAY

ASSESSMENT PATIENT

 Players
1. Patient (P) : Descagian Rahman Amkantari
2. Patient Wife (W) : Lilik Sugianti
3. Doctor (D) : I Gede Panji Santika
4. Nurse I (N1) : Bq Reni Komala Sari
5. Nurse II (N2) : I. G. A. Ayu Switari. P. S
6. Nurse III (N3) : Bq Azila Falasifa
7. Nurse IV (N4) : Asyafia Rizkika
8. Nurse V (N5) : Bunga Puspita
9. Nurse VI (N6) : Balqis Muti’ah
10. Nurse VII (N7) : Ni Putu Grahita Kirana
11. Nurse VIII (N8) : Lilis Idaratul Fahmi

 Convertation
N1 : Good Morning Mr. Have a seat please.
P : Alright. Thank you
N1 : I will collect your personal details and assess you. Is that okay ?
P : Of course.
N1 : Okay. Your complete name, please ?
P : I’am Justin Pattinson
N1 : Can you spell it please ?
P : Alright. J-U-S-T-I-N and P-A double T-I-N-S-O-N
N1 : Alright. What would you like to call ?
P : Call my first name that’s fine.
N1 : So, it must be Justin, right ?
P : Yes, that’s right.
N1 : May I know your date of birth ?
P : December 20, 1956
N1 : It would be 62 years this December right ?
P : Yes, I am
N1 : Where are you come from Mr, Justin ?
P : I came from Mataram
N1 : Alright. Could you tell me about your last education ?
P : Yes, sure. I’am a bachelor.

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N1 : And your occupation ?
P : I’m a teacher.
N1 : May I know your religion ?\
P : I’am cristian
N1 : Alright. Thank you for your information. Now I will axamine you. Are you
agree ?
P : Sure, I agree.
N1 : Okay so wait a few minute. I will prepare to examine you.
P : Okay, thank you.

N2 : Alright, let’s we take an assessment.


P : Alright
N2 : What’s matter with you ?
P : My feet very hurt. It suddenly like this (pointing his calus). When an ant bite
my feet than I scratch it. And tomorrow in the morning this wound appeared.
And I just leave it and do nothing, cause I think it’s a small problem and it will
recover soon.
N2 : Alright. Did you have any complaint ?
P : Yeah sure. Lately I felt very dizzy too.
N2 : May I see your wound ?
P : Of course.
N2 : Did your family had the same complaint with you ?
P : Yeah sure. My mother had the same complaint as I did.
N2 : It’s a diabetic wound Mr.
P : What is that Nurse ?
N2 : Diabetes is a disorder in which the level blood sugar is persistently raised
above the normal range.
P : Is that dangerous ?
N2 : Yes, of course. It’s dangerous. You even could be dead cause this problem.
P : So, what should I do ?
N2 : Let’s we check your blood sugar level first. Than we’ll know what to do.
P : Alright let’s check it.

N3 : Let’s have a seat, please Mr.


P : Alright, thank you.
N3 : Give me your middle finger,please
P : Okay. (give his midle finger)
N3 : (Checking his blood sugaR) your blood sugar level is 423 Mr. Justin
P : Is it high ?
N3 : Sure, it’s too high Mr.

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P : What a normal level of blood sugar ?
N3 : It’s 90-200 Mr. I’ll take your blood pressure. Give me your right hand and roll
up your sleeve.
P : (Do a nurse intruction)
N3 : Your blood pressure is 150/90 mmHg, Sir.
P : It’s too high right ?
N3 : Surely. It’s too high, Mr. Justin.
P : So, what should I do nurse ?\
N3 : You should take a treathment care from hospital for make you recover. Are you
agree ?
P : Yes, I agree. I wanna recover soon nurse.
N3 : Okay, let’s we consultation with the doctor.

Pattient entering the doctor room’s


P : Excuse me.
D : Have a sit please. Mr.
P : Alright, thank you doc.
D : Mr. Justin Pattinson right ?
P : Yes. Alright.
D : From your information you should take a treathment care in hospital untill your
blood pressure and you’re blood sugar stay normal. Because your blood pressure
and your blood sugar too high. So, if you dicipline to follow the treathment. You
will recover soon.
P : Oke if it’s better for me
D : Oke. If you agree. Than the nurse will take care of your admission.
P : Thank you, Doc
D : Nurse Asya, please take care for Mr. Justin.
N4 : Alright Doc.
N4 : Alright Mr and Mrs Justin. Please follow me to fill the hospital form.
P : Okay

N5 : Okay Mr. Justin before you take a treathment care in this hospital. We need
your regent detail’s too.
P : Alright. This is my wife as a regent.
N5 : AlrightMrs. May I know your complete name ?
W : I am Letty Grande
N5 : What should I call you ?
W : Call me Letty that’s okay.
N5 : How old are you ?
W : I’m 57 years this month.

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N5 : Okay. May I know your last education ?
W : My education and my occupation same with my husband. We are just from
different department.
N5 : Alright. So your husband officialy taking care in this hospital. Than Ners Lilis
will show you the room.
N6 : Follow me ,please Mr and Mrs.

Arrived in the room


N6 : This is your room Mr. Justin. You have to take a rest here and I will wearing
you a IV chateter.
J : Alright, Thank you Ners.
N6 : (Wearing the chateter) Okay it’s done Mr. Justin.
J : Okay thank you very much ners.

A few minute later Nurse VII (N7) turn to the Mr. Justin room to assess his nutrition and
his elimination
N7 : Excuse me, Mr and Mrs Justin.
P&W : Alright coming please ners.
N7 : I’m here to ask you some question are you agree ?
P : Okay I agree
N7 : How many times do you ate a day ?
P : I ate 3 times a day.
N7 : Which is portion ?
P : In adult portion
N7 : You finished it ?
P : Yeah, I finished it.
N7 : And ho many time you drink water ?
P : I drink 5 glasses of water a day
N7 : And what about now ?
P : Since I getting sick, I just ate twice a day and only two tablespoon from the food
that provided in hospital cause everytime I eat I feel nausea and I just drink a glass
of water a day.
N7 : Did you urinate normaly ?
P : Sure I urinate normaly before at least 3 times a day. But when I got this
problem. I rarely urinate cause my feet is hurt and now using this catheter to make
it easier.
N7 : How many times you defecate a day ?
P : Before I sick I can defecate normaly once a day in morning. But now I never
defecate cause it’s difficult to go toilet.

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N7 : Alright, thanks for your information. The other nurse will coming a few minute
later for assess you.
P : Alright. Thank you ners.

A few minute later Nurse VIII (N8) turn to the Mr. Justin room to assess his wound on the
right extremity and his skin around the wound.
N8 : Excuse me, Mr and Mrs Justin.
P&W : Alright coming please ners.
N8 : I’m here to check your wound on your feet and your skin around the wound.
P : Yes, please.
N8 : Is it still hurt ?
P : Yes, it still hurt.
N8 : What do you feel on your wound right now ?
P : It’s feel like a stabbed feeling.
N8 : From 0-10 pain scale. What the scale for your wound ?
P : It’s 7 nurse.
N8 : Alright. Your wound has red colour, unthermal, swollen, no pus, and moist
P : Is that okay ners ?
N8 : Yes that’s okay as long as you keep discipline to follow your diet program.
P : Of course, I will discipline to follow the program.
N8 : Alright. Thanks for your information Mr and Mrs Justin.
P : Okay. You’re welcome ners.

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